To describe methods for making viable referrals for specialized treatment and/or other community services for substance use disorders.
The following discussion of referral techniques is reproduced with permission from the proceedings of the Josiah Macy, Jr. Foundation sponsored conference on Training about Alcohol and Substance Abuse for All Primary Care Physicians:
Physicians should be able to consult with, and refer patients to, addiction specialists, alcohol and drug treatment programs, and mutual self-help groups.
There are a number of clinical situations in which a primary care physician may want to consult an addiction specialist or refer a patient to an addiction treatment program. These programs can provide diagnostic assessments of patients who may be suffering from the adverse effects of substance use. It may be difficult for a primary care physician with limited time to conduct the full assessment necessary, especially in patients who are given medications such as sedatives or opioids. Many specialists and alcohol and drug counselors are willing to conduct such assessments in hospital settings or physicians' offices. Following the assessment, they can work with the physician, the patient, and family members to develop a treatment plan.
Persons who have evidence of physical dependence on drugs often require detoxification and specialized treatment. While most patients can be safely withdrawn by primary care physicians, polysubstance users, persons using intravenous drugs, and those with medical problems may require inpatient care under the supervision of an addiction specialist. Once detoxification is completed, the treatment of choice is a specialized program that includes education, group therapy, one-on-one counseling, and mutual self-help groups.
Another clinical indication for referral is for those patients with alcohol-related health problems. Persons with evidence of a substance-related problem, such as hepatitis, pancreatitis, or depressions, who need to become abstinent should be referred to a specialized program. While they may not require the intense therapy that persons with evidence of physical dependence need, the presence of a medical problem suggests that continued substance use could lead to a potentially fatal condition. They should receive as much treatment as possible before their medical problems deteriorate secondary to continued use.
A third group of patients who may be referred are those who have been unable to change their substance use behavior following an office-based intervention. Patients who are unable to maintain their use at a low-risk level may be alcohol- or drug-dependent and require more intense therapy than can be provided in a physician's office. For example, at-risk drinkers who are unable to stop binge drinking may benefit from cognitive behavioral therapy.
One of the difficulties physicians confront when trying to refer patients to an addiction specialist or treatment program is a lack of knowledge regarding available specialists and programs in their communities. Methods that can be used to access alcohol and drug specialists in the community include:
Since many patients have limited insurance or resources that will pay for alcohol or drug treatment, physicians may want to develop a list of publicly funded or self-help community programs.
Physicians may want to call the directors of local treatment programs to determine the ranges of services provided by those programs. They may want to inquire about:
Physicians may also want to ask about the use of treatment methods that are not based on the tenets of Alcoholics Anonymous, such as motivational therapy, cognitive therapy, and couples therapy.
There are a number of methods that increase the likelihood that patients will follow through on an alcohol or drug referral. First, the physician should tell the patient that he would like a second opinion from a specialist. The medical aspect of the referral should be emphasized to minimize the stereotypical response associated with referral to an alcohol treatment program. The physician should help the patient set up the appointment by making the phone call while the patient is in the examination room. The importance of the referral should be stressed and the patient should be told that this referral is no different from a referral to any other type of specialist, such as a cardiologist for a heart condition. A referral letter summarizing the patient's medical problems and the reason for the referral should be sent prior to the patient's appointment with the specialist. Finally, the physician should ask the addiction specialist or counselor to contact the physician after the assessment or if the patient fails to show up for the appointment. The physician should inform the consultant that he would like to participate in treatment planning and provide long-term follow-up. Patients should sign a consent form that allows communication between the primary care physician and the treatment program.
If the patient refuses to see an addiction specialist or does not have the financial resources to follow through, a number of strategies can be utilized. The physician should identify recovering alcoholics in the community who are willing to meet with the patient to discuss methods for changing drinking behavior. Also, the local Alcoholics Anonymous will usually serve as a rich resource. Whenever possible, it is important to match patients with recovering persons of the same gender, similar age, and socioeconomic status.
Another suggestion is to ask the patient to attend a mutual-help group meeting such as Alcoholics Anonymous or Narcotics Anonymous. Most communities have several meetings every day that are open to anyone who is interested in becoming sober. The physician should suggest that the patient attend several meetings in different locations to find a compatible group that fits the patient's personal needs. Patients should be directed to specific programs that are more likely to meet their needs. Women, in particular, may do better in an all-female group, which may be more sensitive to issues such as sexual abuse. Alternative meetings that do not use a 12-step approach include Rationale Recovery and Women for Sobriety.
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Study Questions:
Are the following statements true or false?