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134
T. N. Goring and I. L. Nelson
Pain at the end of life also has an existential component—
profound questions about the meaning of one’s life and of
things done and not done. Conversation with loved ones and
spiritual advisors may help patients explore these questions.
And, although controversial, evidence suggests that existential pain can be managed with acetaminophen [7].
Conclusion
Caring for patients at the end of their lives is an important
part of primary care medicine. Decades of medical literature
have shown that, at the end of life, most people hope for dignity, comfort, the company of loved ones, and peace—none of
which can be found in an intensive care unit. By using the
tools of palliative and hospice medicine in your practice, you
can provide these things. While the task may seem daunting,
the benefits to your patients are immeasurable.
Clinical Pearls
• Palliative care is specialized care for individuals with seri-
ous, often life-limiting illness.
• Patients with a predicted life expectancy of <6 months
qualify for hospice care.
• Primary care physicians should feel comfortable discussing
goals of care with patients.
• The two most important advanced care documents are the
health care proxy and the MOLST form.
• Palliative care can be delivered concomitantly with disease-
directed therapies.
• Goals of care discussions should happen early and be reas-
sessed as things change.
Don’t Miss This!
• Do not forget to evaluate for reversible causes of shortness
of breath.
• Shortness of breath can be managed with oxygen and opi-
oids at the end of life.
Chapter 5. Care at the End of Life: Palliative…
135
• Obstruction should be ruled out in a patient with nausea/
vomiting.
• When treating pain, begin with non-opioid analgesics, if
appropriate.
• Always prescribe a bowel regimen along with opioids.
• When giving multiple medications to control nausea/vom-
iting, choose those with different mechanisms of action.
Resources
CAPC website: a very valuable source of information, educational materials, and resources.
Oxford Textbook of Palliative Medicine. Oxford University
Press. This is also available in a shortened, pocket sized version. A good source of information for assessment and treatment of symptoms.
References
1. Temel JS, etal. Early palliative care for patients with metastatic
non-small-cell lung cancer. N Engl J Med. 2010;363:733–42.
2. May P, et al. Economics of palliative care for hospitalized
adults with serious illness, a meta analysis. JAMA Intern Med.
2018;178(6):820–9.
3. https://www.cms.gov/medicare- coverage- database/view/lcd.
aspx?LCDId=34538
4. https://www.capc.org
5. Bullock K.The inuence of culture on end-of-life decision mak-
ing. J Soc Work End Life Palliat Care. 2011;7(1):83–98. https://doi.
org/10.1080/15524256.2011.548048.
6. Buckman R. Breaking bad news: the S-P-I-K-E-S strategy.
Commun Oncol. 2005;2(2):138–42.
7. Randles D, etal. The common pain of surrealism and death: acet-
aminophen reduces compensatory afrmation following meaning
threats. Psychol Sci. 2013;24(6):966–73.
8. World Health Organization. Cancer pain relief. Geneva: World
Health Organization; 1986.
Chapter 6
Substance Use Disorder
KimberlyCartmill
Introduction
Untreated alcohol and opioid use disorders lead to increased
morbidity, mortality, and hospital spending [1]. Treatment for
substance use disorder decreases mortality and prevents
relapse [2–4]. Despite the availability of effective, evidencebased treatment, it is estimated that only 25% of patients
with opioid use disorder and under 10% of patients with
alcohol use disorder receive treatment annually [5]. Primary
care providers have a unique opportunity to identity and
engage patients with risky substance use and substance use
disorders (SUD).
This chapter will focus on unhealthy use of alcohol and
opioids. The same guidelines for screening and counselling
apply to other substances, such as cannabis and cocaine.
Alcohol and opioid use disorders are highlighted due to their
prevalence and significant impact on individual health and
K. Cartmill (*)
Department of Internal Medicine, Jacobi Medical Center,
Bronx, NY, USA
e-mail: Cartmilk@nychhc.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_6
137
138
K. Cartmill
society. In addition, opioid, alcohol, and tobacco are the only
substance use disorders with FDA-approved medications
which should be prescribed in the primary care clinic.
Definitions
Substance use exists in a spectrum and changes throughout
a person’s lifetime. While the majority of people in the
United States consume substances like alcohol without risk
of harm, it is estimated that 24% of primary care patients
have risky substance use, and about 3% have a substance use
disorder [6].
Unhealthy or risky substance use is defined as use that has
the potential to cause harm. For prescription drugs, such as
opioids or benzodiazepines, this would be any use of the
medication in a way other than instructed [7, 8]. This includes
taking a prescription opioid at a higher dosage or frequency
than prescribed or for another indication. For illicit drugs,
such as cocaine or heroin, any use is considered risky [7, 8].
This contrasts with alcohol, in which there is a definition of
risky use [9, 10]:
• For women: drinking eight or more drinks in 1 week OR
four or more drinks in one sitting.
• For men: drinking 15 or more drinks in 1week OR five or
more drinks in one sitting.
Substance use disorder (SUD) is a chronic relapsing brain
disease that causes clinically significant impairment or distress. This diagnosis defined by the DSMV as having at least
2 of 11 criteria [11]:
• Using larger amounts/longer than intended.
• Repeated attempts to quit/control use.
• Craving.
• Much time spent using.
• Activities given up in order to use.
• Neglected major role in order to use.
• Physical/psychological problems associated with use.
Chapter 6. Substance Use Disorder
• Hazardous use.
• Social/interpersonal problems related to use.
• Withdrawal*.
• Tolerance*.
Please note that withdrawal and tolerance WITHOUT
other criteria does not qualify. These two criteria alone are
physiological results of continued use known as dependence.
139
Decision-Making
Identification
The US Preventive Services Task Force recommends screening patients over the age of 18 for unhealthy alcohol and drug
use [12, 13]. There needs to be a follow-up process for engagement or referral to treatment for positive screens. While the
guidelines do not specify the recommended frequency, screening high-risk individuals (younger than 25 years; having a
psychiatric disorder, nicotine or alcohol dependence; having
experienced physical or sexual abuse in childhood; having a
personal or family history of drug or alcohol addiction; having chronic pain; and having easy access to prescription
drugs) on an annual basis seems reasonable.
There are validated screening tools available to identify
and risk-stratify patients with unhealthy substance use. It is
recommended that the patient independently and confidentially complete the screening. This starts with a one-question
screen for alcohol and drug use [7, 14–16]:
• Alcohol screen [7, 14, 16].
– Men: How many times in the past year have you had
five or more drinks in a day?
– Women: How many times in the past year have you had
four or more drinks in a day?
A positive screen is 1 or above. This should be followed up
with the AUDIT [17]. Please note that it is important to
define a “standard” alcoholic drink when screening patients.
140
K. Cartmill
This is defined as 12 fluid ounces of beer (one standard can),
5 fluid ounces of table wine (one glass), and 1.5 fluid ounces
of spirits (one shot glass).
• Drug screen [7, 15, 16]: How many times in the past year
have you used an illegal drug or used a prescription medi-
cation for nonmedical reasons?
A positive screen is 1 or above. This should be followed up
with the DAST-10 [18, 19].
The DAST-10 and AUDIT scores risk stratify the patient
into no or low risk, at risk, moderate/high risk and severe risk.
This helps to identify the best treatment strategy for the
patient (Fig.6.1).
Key History
Patients with risky substance use and substance use disorder
require special consideration. These patients have likely suffered due to stigma, a history of trauma, and co-occurring
psychiatric conditions [20]. It is important to approach each
interaction with respect and compassion. It should be emphasized that all physician-patient discussions are confidential
while acknowledging that clinicians are mandatory reporters.
If there is a concern that a patient’s substance use is putting
a dependent at risk, the appropriate authorities need to be
notified.
The initial history taking in a patient with risky substance
use is similar to any other visit. Although the clinician may be
aware of the patient’s substance use before the encounter, it
is important to approach the patient with the same agendasetting opening recommended for all patients. Beginning with
open-ended questions such as “How can I help you today?”
or “What would you like to discuss during this visit?” may
prompt the patient to bring up substance use. However, many
patients may not spontaneously disclose they would like to
discuss this.
The clinician should bring up the patient’s substance use if
the patient fails to do so. This may be broached during the
Chapter 6. Substance Use Disorder
Assess for substance use
disorder (SUD) by DSMV
criteria**
• Counsel on diagnosis and
management**
• Referral to treatment program
Mod/High risk use and Severe use
AUDIT score 16-19/Severe use: 20+
DAST 3-5/ Severe use: 6+
• Harm Reduction
141
• Close follow up with clinic team to
ensure referral accomplished
screener
Positive 1 item drug
screener
Positive 1 item alcohol
Perform DAST-10
Perform AUDIT
At risk
AUDIT score 8-15
DAST 1-2
Low/No Risk
AUDIT score 0-7
DAST 0
• Motivation Interviewing
• Patient Education
• Harm Reduction
• Brief intervention (BI):
• Close follow up with clinic team to ensure
Continue Standard
practices to prevent risky
use
goals of BI accomplished
F . Proposed screening for unhealthy substance use in primary care [7, 16–19]
142
K. Cartmill
routine social history elicited at each new patient visit. While
assessing the patient’s tobacco, drug, and alcohol use, it is
important to avoid leading questions. For instance, simply
stating “How often do you drink alcohol?” and “How often
do you use drugs or medication not prescribed to you?” are
good opening questions. If a patient states he or she never
drinks, an inquiry as to why is recommended as the majority
of American adults have consumed alcohol at least once [21].
Prior to further discussion into a patient’s substance use, it
is recommended to ask permission. For instance, “Would it be
OK to discuss this further?” or “I would like to learn more
about your drinking, would that be OK?” If the patient
agrees, the clinician can then continue with nonjudgmental
questions to better understand the patient’s own perspectives
about current substance use and its consequences. A sample
discussion would include the following:
Current use: Identify the type, quantity, route, and last use
for each substance.
• Assess if there is sharing of materials used for intranasal or
intravenous drug use. While risk of hepatitis and HIV
transmission through sharing needles is common knowl-
edge, the risk of sharing other supplies can be overlooked.
For instance, hepatitis C can be acquired by sharing sup-
plies such as water when injecting drugs [22]. Hepatitis C
can even be found on straws used for intranasal drug con-
sumption [23].
Consequences: Ask if their substance use has led to problems with the law, finances, employment, relationships, or
health.
• Legal: incarceration, parole, and citations (such as driving
under the influence).
• Employment or financial: job loss, bankruptcy, and hous-
ing insecurity.
• Relationship: neglect or abuse of dependents, loss of rela-
tionships, or parental rights.
• Health problems: liver, lung, heart, brain, or kidney dis-
ease; trauma; impacts on chronic disease management
(diabetes, hypertension, heart failure); erectile disfunction;
Chapter 6. Substance Use Disorder
and infections like HIV, STIs, cellulitis, abscesses,
endocarditis.
– Prior overdoses, as well as substance-related emergency
room and hospital visits, should be documented.
Patient’s impression of substance use:
• Has the patient thought about and/or tried to cut down
prior?
– If so, why? What happened?
• Does the patient think substance use is causing or contrib-
uting to any problems?
– If no, do their friends or loved ones think so? If so, why?
If the patient expresses a desire to seek help for substance
use during the visit, a more detailed substance use history can
be pursued. The clinician can guide the patient to recount the
substance use history from the first use until the present. This
history may guide the management plan.
143
Workup
A detailed history guides the appropriate workup. The goal of
laboratory or imaging studies is to determine if the patient
has health problems related to substance use, ensure safety,
and prevent substance-related diseases.
For patients with alcohol or opioid use disorders, initial
laboratory analysis should include the following [20]:
• Complete blood count (CBC) to identify anemia and
thrombocytopenia.
• Liver and kidney tests (CMP).
• Infectious disease workup: HIV antibody, hepatitis serolo-
gies (hepatitis A, B, and C); syphilis and tuberculosis test-
ing can also be considered.
– If patients lack immunity, provide vaccinations for
hepatitis A and B.
144
K. Cartmill
– If HIV negative and at high risk for acquisition, dis-
cussion of HIV pre-exposure prophylaxis is recommended.
• Urine tests: Toxicology is recommended for all. This can
identify substances that patients may not be aware they
are consuming.
• Pregnancy tests for women of child-bearing age.
• For patients with opioid use disorder, an EKG can be con-
sidered prior to starting methadone or suboxone to assess
the patient’s QT interval.
Management
Harm Reduction Any patient with risky substance use should
have harm reduction counselling. Harm reduction is the
concept of making risky behaviors less dangerous. Some
examples include the following recommendations:
• Do not drive or operate machinery under the influence.
• Do not use alone.
• Do not mix substances.
• Do not share drug paraphernalia.
Any treatment plan should emphasize patient- centeredness
and harm-reduction. Lecturing the patient or presenting
abstinence as the only viable option could be harmful. While
abstinence may be the goal for some patients, others may
wish to cut down on their use to improve their financial, interpersonal, or health issues.
Risky or Unhealthy Alcohol Use
Low Risk These patients have an AUDIT score of 8–15.
There is good evidence that providing patients with risky
alcohol use with brief interventions can decrease their number