A Synoposis of AFP's "A Primary Care Approach to Substance Misuse"

A Primary Care Approach to Substance Misuse
BRAD SHAPIRO, MD; DIANA COFFA, MD; and ELINORE F. McCANCE-KATZ, MD, PhD University of California, San Francisco, School of Medicine, San Francisco, California
Am Fam Physician. 2013 Jul 15;88(2):113-121
 http://www.aafp.org/afp/2013/0715/p113.pdf

     There is a difference between substance abuse and sustance dependence. Abuse is a pattern due to the substance use, that leads to impairment or distress, which may occur from not fulfilling obligations at work, school or home, substance related legal issues, involvement in dangerous situations, or social/ interpersonal problems. Dependence is seen in patients who display tolerance, withdrawal, a desire to want to stop, giving up previously enjoyed activities, spending a lot of time getting the substance, and using more for longer times.
     Substance abuse should be considered a chronic illness like asthma or diabetes. The management of substance abuse starts with screening, assessing comorbidities, counseling, follow up, and treatment referral, if necessary. Although not recommended by the USPSTF, screening may be justified because of the high prevalence and morbidity of the disease. A screening questionnaire can be employed to help determine if substance abuse is occurring. Counseling the patient can decrease the amount of drug use. This article briefly describes some interviewing techniques which I recommend reading. Most of the principles talk about having the patient come up with the idea or having the patient have "self discovery" rather then "telling them" what to do. The patient will use the consequences of substance use to be the motivation for change.
     The three drugs that can be used to treat opioid dependence are buprenorphine, naltrexone, and methadone. Treatment should have a long term approach with a slow taper. Buprenorphine is a partial mu opioid receptor agonist that can be mixed with naloxone to prevent misuse. Methadone is distributed through special federal programs. Naltrexone is a mu opioid receptor antagonist which can be helpful in patients trying to maintaining abstinence  It has had limited success in non motivated patients. There is not pharmacologic treatmetns for stimulants. Referral to specialized treatment centers can be very helpful and appropriate.  Comorbid mental health conditions may be occurring concomitantly. Patients should be followed up often and regularly.