Applied Evidence

CASE Mr. A, a 59-year-old high school science teacher, came into our medical clinic with severe pain (7/10) in his left shoulder and arm and weakness on flexion of his left elbow. A week earlier, he felt a “pop” and experienced sharp pain and immediate “swelling” of the left biceps after throwing a heavy trash bag away while at work. He went to the school nurse for evaluation and was referred to a physician.

Mr. A was healthy, had no chronic diseases, and reported no previous injuries or trauma. He denied smoking, drinking alcohol, using illegal drugs, or taking steroids or other medications. He had worked as a high school teacher for the last 10 years at the time of his clinic visit.

Imaging, physical exam tell the tale. The patient’s physical exam was normal, with one outstanding exception: a “Popeye” deformity in his left biceps (FIGURE), accompanied by severe pain and tenderness to palpation over the proximal aspect of the left biceps. Both active and passive range of motion of the elbow were full and symmetrical, but the patient had prominent pain and weakness on elbow flexion and supination. However, he had good rotator cuff strength without pain and no impingement signs or acromioclavicular joint pain. He had no atrophy or scapular dyskinesia. Similarly, a neurovascular exam of the distal aspect of the extremity was normal.

FIGURE
“Popeye” deformity in left biceps

The magnetic resonance imaging report revealed a complete tendon rupture of the long head of the biceps brachii muscle. The long head muscle was intact and there was a posttraumatic hemorrhage in the region of the tear in the upper arm. The remaining muscle, ligaments, and tendon were intact. There was no evidence of a fracture.

A 3-pronged approach. Once the diagnosis of acute complete rupture of the left long head tendon biceps brachii was reached, we laid out a 3-pronged treatment approach:

• nonsteroidal anti-inflammatory agents and muscle relaxants such as cyclobenzaprine, tizanidine, or metaxalone
• physical therapy (2-3 times per week) and daily home exercise
• modified activities—specifically, no overhead work or lifting of anything >10 lb with the affected arm.

Before we proceeded with this plan, we referred the patient to a specialist for evaluation and a second opinion.

Biceps tendon rupture usually follows a traumatic event

Long head biceps tendon ruptures often involve people between 40 and 60 years of age, with men affected significantly more often than women.^1,2 Tennis players and ballplayers are also affected, as a result of frequent swinging motions.³ As you might expect, a person’s dominant arm is more often affected.³

Excessive weightlifting or rapid stress upon the tendon can cause an acute tendon rupture. As a rule, biceps tendon ruptures are caused by a single traumatic event that typically involves lifting a heavy object while the elbow is bent at a 90-degree angle. Weight lifters who use anabolic steroids are at an increased risk of sustaining a rupture at the tendon, and clinicians may also see such ruptures among patients who have fallen forcefully onto an outstretched arm.^2,3

Keep in mind, however, that rupture can also occur in the absence of a traumatic event. This usually happens in elderly individuals with advanced tendon degeneration.⁴ Smoking, rheumatoid arthritis, steroid medications,^2,5 fluoroquinolones,⁶ and statin therapy⁷ can affect this tendon and increase the risk of spontaneous rupture, as well.

“Popeye” biceps—a telltale sign. Understanding the function of the biceps brachii helps explain at least one of the telltale signs of long head tendon rupture. The biceps muscle enables supination of the forearm and flexion of the elbow. With long head tendon rupture, however, the muscle belly retracts, causing prominent fullness and bulging of the upper arm—what’s called “Popeye” biceps. Because the rupture involves only the long head tendon of the biceps and not the short head tendon, the biceps still functions.⁸

Surgical repair vs conservative management

Whether to pursue surgery or conservative management when caring for a patient with a biceps rupture remains a subject of debate in the medical literature. There are no studies that demonstrate the superiority of one approach over the other.^2,5,9,10

Surgery. The serious complications associated with surgery have led some experts to question whether the risks of surgery outweigh the benefits.¹¹ Equally important is the patient’s individual circumstances. Clinicians need to consider each patient’s occupation, lifestyle, and age when recommending a course of action.

Published clinical guidelines usually recommend surgical repair for young athletes who require maximum supination strength in daily activities. Although the size of the Popeye deformity does diminish after conservative treatment, surgery is often recommended for patients who are unwilling to accept the cosmetic defect seen after the tendon ruptures. And finally, operative treatment is indicated for middle-aged carpenters and manual laborers whose occupations require full supination and arm strength.^2,12-14

The surgical procedure, called tenodesis, involves reattaching the torn section of the tendon to the bone.^5,15 A recent study involving 5 professional wrestlers injured while performing noted that tenodesis restored full biceps function, gave excellent cosmetic results, and allowed all of the young men to return to wrestling.¹⁵

Conservative treatment. A conservative approach is appropriate for older patients when their profession and lifestyle do not demand a high degree of supination and upper arm strength.^5,8,13,14 In addition, the more conservative approach is very well tolerated, which reduces the risk of serious complications and the cost of surgery.¹¹ Avoiding surgery also permits patients to return to work much sooner.

Patients may, however, lose up to 20% of their supination strength with conservative treatment.¹⁴ But this approach does not cause weakness in grip, pronation, or elbow extension. Nor does it affect patients’ activities of daily living,¹⁴ which may explain why more patients are treated conservatively than with surgery.^5,11 Additionally, some experts recommend nonoperative treatment of distal biceps tendon ruptures for people who are wary of surgery or present late with the injury.¹¹

CASE Two orthopedic surgeons examined our patient and both supported our recommendation to pursue conservative treatment for Mr. A.

Over the next 4 to 6 weeks, he received physical therapy 2 to 3 times per week. With the help of the physiotherapist, Mr. A performed joint mobilization and flexibility exercises to improve the range of motion in his shoulder. The therapist also helped him with strengthening and stretching exercises to restore the strength of his biceps and elbow muscle.

At home, our patient’s regimen included elbow bend and straighten movements, elbow supination and pronation movements, and static biceps contractions.

Over time, his pain diminished and the strength in his left arm improved. Mr. A was able to return to work with modified duty, 2 to 3 weeks after his injury. By Week 8, he had full range of motion in his left arm and normal strength. He was able to do his job as a high school science teacher without any restrictions, but continued to have the Popeye deformity.

Our experience treating Mr. A serves as a reminder to physicians that complete long head biceps tendon rupture can be successfully treated conservatively. Patients working in sedentary occupations usually do not need a high degree of supination or physical strength in their upper extremities, making this a worthwhile treatment option for them.

CORRESPONDENCE 
Sofya Pugach, MD, PhD, MPH, Complete Med Care, 8989 Forest Lane, Dallas, TX 75243; Drpugach@yahoo.com

CASE Mr. A, a 59-year-old high school science teacher, came into our medical clinic with severe pain (7/10) in his left shoulder and arm and weakness on flexion of his left elbow. A week earlier, he felt a “pop” and experienced sharp pain and immediate “swelling” of the left biceps after throwing a heavy trash bag away while at work. He went to the school nurse for evaluation and was referred to a physician.

Mr. A was healthy, had no chronic diseases, and reported no previous injuries or trauma. He denied smoking, drinking alcohol, using illegal drugs, or taking steroids or other medications. He had worked as a high school teacher for the last 10 years at the time of his clinic visit.

Imaging, physical exam tell the tale. The patient’s physical exam was normal, with one outstanding exception: a “Popeye” deformity in his left biceps (FIGURE), accompanied by severe pain and tenderness to palpation over the proximal aspect of the left biceps. Both active and passive range of motion of the elbow were full and symmetrical, but the patient had prominent pain and weakness on elbow flexion and supination. However, he had good rotator cuff strength without pain and no impingement signs or acromioclavicular joint pain. He had no atrophy or scapular dyskinesia. Similarly, a neurovascular exam of the distal aspect of the extremity was normal.

FIGURE
“Popeye” deformity in left biceps

The magnetic resonance imaging report revealed a complete tendon rupture of the long head of the biceps brachii muscle. The long head muscle was intact and there was a posttraumatic hemorrhage in the region of the tear in the upper arm. The remaining muscle, ligaments, and tendon were intact. There was no evidence of a fracture.

A 3-pronged approach. Once the diagnosis of acute complete rupture of the left long head tendon biceps brachii was reached, we laid out a 3-pronged treatment approach:

• nonsteroidal anti-inflammatory agents and muscle relaxants such as cyclobenzaprine, tizanidine, or metaxalone
• physical therapy (2-3 times per week) and daily home exercise
• modified activities—specifically, no overhead work or lifting of anything >10 lb with the affected arm.

Before we proceeded with this plan, we referred the patient to a specialist for evaluation and a second opinion.

Biceps tendon rupture usually follows a traumatic event

Long head biceps tendon ruptures often involve people between 40 and 60 years of age, with men affected significantly more often than women.^1,2 Tennis players and ballplayers are also affected, as a result of frequent swinging motions.³ As you might expect, a person’s dominant arm is more often affected.³

Excessive weightlifting or rapid stress upon the tendon can cause an acute tendon rupture. As a rule, biceps tendon ruptures are caused by a single traumatic event that typically involves lifting a heavy object while the elbow is bent at a 90-degree angle. Weight lifters who use anabolic steroids are at an increased risk of sustaining a rupture at the tendon, and clinicians may also see such ruptures among patients who have fallen forcefully onto an outstretched arm.^2,3

Keep in mind, however, that rupture can also occur in the absence of a traumatic event. This usually happens in elderly individuals with advanced tendon degeneration.⁴ Smoking, rheumatoid arthritis, steroid medications,^2,5 fluoroquinolones,⁶ and statin therapy⁷ can affect this tendon and increase the risk of spontaneous rupture, as well.

“Popeye” biceps—a telltale sign. Understanding the function of the biceps brachii helps explain at least one of the telltale signs of long head tendon rupture. The biceps muscle enables supination of the forearm and flexion of the elbow. With long head tendon rupture, however, the muscle belly retracts, causing prominent fullness and bulging of the upper arm—what’s called “Popeye” biceps. Because the rupture involves only the long head tendon of the biceps and not the short head tendon, the biceps still functions.⁸

Surgical repair vs conservative management

Whether to pursue surgery or conservative management when caring for a patient with a biceps rupture remains a subject of debate in the medical literature. There are no studies that demonstrate the superiority of one approach over the other.^2,5,9,10

Surgery. The serious complications associated with surgery have led some experts to question whether the risks of surgery outweigh the benefits.¹¹ Equally important is the patient’s individual circumstances. Clinicians need to consider each patient’s occupation, lifestyle, and age when recommending a course of action.

Published clinical guidelines usually recommend surgical repair for young athletes who require maximum supination strength in daily activities. Although the size of the Popeye deformity does diminish after conservative treatment, surgery is often recommended for patients who are unwilling to accept the cosmetic defect seen after the tendon ruptures. And finally, operative treatment is indicated for middle-aged carpenters and manual laborers whose occupations require full supination and arm strength.^2,12-14

The surgical procedure, called tenodesis, involves reattaching the torn section of the tendon to the bone.^5,15 A recent study involving 5 professional wrestlers injured while performing noted that tenodesis restored full biceps function, gave excellent cosmetic results, and allowed all of the young men to return to wrestling.¹⁵

Conservative treatment. A conservative approach is appropriate for older patients when their profession and lifestyle do not demand a high degree of supination and upper arm strength.^5,8,13,14 In addition, the more conservative approach is very well tolerated, which reduces the risk of serious complications and the cost of surgery.¹¹ Avoiding surgery also permits patients to return to work much sooner.

Patients may, however, lose up to 20% of their supination strength with conservative treatment.¹⁴ But this approach does not cause weakness in grip, pronation, or elbow extension. Nor does it affect patients’ activities of daily living,¹⁴ which may explain why more patients are treated conservatively than with surgery.^5,11 Additionally, some experts recommend nonoperative treatment of distal biceps tendon ruptures for people who are wary of surgery or present late with the injury.¹¹

CASE Two orthopedic surgeons examined our patient and both supported our recommendation to pursue conservative treatment for Mr. A.

Over the next 4 to 6 weeks, he received physical therapy 2 to 3 times per week. With the help of the physiotherapist, Mr. A performed joint mobilization and flexibility exercises to improve the range of motion in his shoulder. The therapist also helped him with strengthening and stretching exercises to restore the strength of his biceps and elbow muscle.

At home, our patient’s regimen included elbow bend and straighten movements, elbow supination and pronation movements, and static biceps contractions.

Over time, his pain diminished and the strength in his left arm improved. Mr. A was able to return to work with modified duty, 2 to 3 weeks after his injury. By Week 8, he had full range of motion in his left arm and normal strength. He was able to do his job as a high school science teacher without any restrictions, but continued to have the Popeye deformity.

Our experience treating Mr. A serves as a reminder to physicians that complete long head biceps tendon rupture can be successfully treated conservatively. Patients working in sedentary occupations usually do not need a high degree of supination or physical strength in their upper extremities, making this a worthwhile treatment option for them.

CORRESPONDENCE 
Sofya Pugach, MD, PhD, MPH, Complete Med Care, 8989 Forest Lane, Dallas, TX 75243; Drpugach@yahoo.com

CASE Mr. A, a 59-year-old high school science teacher, came into our medical clinic with severe pain (7/10) in his left shoulder and arm and weakness on flexion of his left elbow. A week earlier, he felt a “pop” and experienced sharp pain and immediate “swelling” of the left biceps after throwing a heavy trash bag away while at work. He went to the school nurse for evaluation and was referred to a physician.

Mr. A was healthy, had no chronic diseases, and reported no previous injuries or trauma. He denied smoking, drinking alcohol, using illegal drugs, or taking steroids or other medications. He had worked as a high school teacher for the last 10 years at the time of his clinic visit.

Imaging, physical exam tell the tale. The patient’s physical exam was normal, with one outstanding exception: a “Popeye” deformity in his left biceps (FIGURE), accompanied by severe pain and tenderness to palpation over the proximal aspect of the left biceps. Both active and passive range of motion of the elbow were full and symmetrical, but the patient had prominent pain and weakness on elbow flexion and supination. However, he had good rotator cuff strength without pain and no impingement signs or acromioclavicular joint pain. He had no atrophy or scapular dyskinesia. Similarly, a neurovascular exam of the distal aspect of the extremity was normal.

FIGURE
“Popeye” deformity in left biceps

The magnetic resonance imaging report revealed a complete tendon rupture of the long head of the biceps brachii muscle. The long head muscle was intact and there was a posttraumatic hemorrhage in the region of the tear in the upper arm. The remaining muscle, ligaments, and tendon were intact. There was no evidence of a fracture.

A 3-pronged approach. Once the diagnosis of acute complete rupture of the left long head tendon biceps brachii was reached, we laid out a 3-pronged treatment approach:

• nonsteroidal anti-inflammatory agents and muscle relaxants such as cyclobenzaprine, tizanidine, or metaxalone
• physical therapy (2-3 times per week) and daily home exercise
• modified activities—specifically, no overhead work or lifting of anything >10 lb with the affected arm.

Before we proceeded with this plan, we referred the patient to a specialist for evaluation and a second opinion.

Biceps tendon rupture usually follows a traumatic event

Long head biceps tendon ruptures often involve people between 40 and 60 years of age, with men affected significantly more often than women.^1,2 Tennis players and ballplayers are also affected, as a result of frequent swinging motions.³ As you might expect, a person’s dominant arm is more often affected.³

Excessive weightlifting or rapid stress upon the tendon can cause an acute tendon rupture. As a rule, biceps tendon ruptures are caused by a single traumatic event that typically involves lifting a heavy object while the elbow is bent at a 90-degree angle. Weight lifters who use anabolic steroids are at an increased risk of sustaining a rupture at the tendon, and clinicians may also see such ruptures among patients who have fallen forcefully onto an outstretched arm.^2,3

Keep in mind, however, that rupture can also occur in the absence of a traumatic event. This usually happens in elderly individuals with advanced tendon degeneration.⁴ Smoking, rheumatoid arthritis, steroid medications,^2,5 fluoroquinolones,⁶ and statin therapy⁷ can affect this tendon and increase the risk of spontaneous rupture, as well.

“Popeye” biceps—a telltale sign. Understanding the function of the biceps brachii helps explain at least one of the telltale signs of long head tendon rupture. The biceps muscle enables supination of the forearm and flexion of the elbow. With long head tendon rupture, however, the muscle belly retracts, causing prominent fullness and bulging of the upper arm—what’s called “Popeye” biceps. Because the rupture involves only the long head tendon of the biceps and not the short head tendon, the biceps still functions.⁸

Surgical repair vs conservative management

Whether to pursue surgery or conservative management when caring for a patient with a biceps rupture remains a subject of debate in the medical literature. There are no studies that demonstrate the superiority of one approach over the other.^2,5,9,10

Surgery. The serious complications associated with surgery have led some experts to question whether the risks of surgery outweigh the benefits.¹¹ Equally important is the patient’s individual circumstances. Clinicians need to consider each patient’s occupation, lifestyle, and age when recommending a course of action.

Published clinical guidelines usually recommend surgical repair for young athletes who require maximum supination strength in daily activities. Although the size of the Popeye deformity does diminish after conservative treatment, surgery is often recommended for patients who are unwilling to accept the cosmetic defect seen after the tendon ruptures. And finally, operative treatment is indicated for middle-aged carpenters and manual laborers whose occupations require full supination and arm strength.^2,12-14

The surgical procedure, called tenodesis, involves reattaching the torn section of the tendon to the bone.^5,15 A recent study involving 5 professional wrestlers injured while performing noted that tenodesis restored full biceps function, gave excellent cosmetic results, and allowed all of the young men to return to wrestling.¹⁵

Conservative treatment. A conservative approach is appropriate for older patients when their profession and lifestyle do not demand a high degree of supination and upper arm strength.^5,8,13,14 In addition, the more conservative approach is very well tolerated, which reduces the risk of serious complications and the cost of surgery.¹¹ Avoiding surgery also permits patients to return to work much sooner.

Patients may, however, lose up to 20% of their supination strength with conservative treatment.¹⁴ But this approach does not cause weakness in grip, pronation, or elbow extension. Nor does it affect patients’ activities of daily living,¹⁴ which may explain why more patients are treated conservatively than with surgery.^5,11 Additionally, some experts recommend nonoperative treatment of distal biceps tendon ruptures for people who are wary of surgery or present late with the injury.¹¹

CASE Two orthopedic surgeons examined our patient and both supported our recommendation to pursue conservative treatment for Mr. A.

Over the next 4 to 6 weeks, he received physical therapy 2 to 3 times per week. With the help of the physiotherapist, Mr. A performed joint mobilization and flexibility exercises to improve the range of motion in his shoulder. The therapist also helped him with strengthening and stretching exercises to restore the strength of his biceps and elbow muscle.

At home, our patient’s regimen included elbow bend and straighten movements, elbow supination and pronation movements, and static biceps contractions.

Over time, his pain diminished and the strength in his left arm improved. Mr. A was able to return to work with modified duty, 2 to 3 weeks after his injury. By Week 8, he had full range of motion in his left arm and normal strength. He was able to do his job as a high school science teacher without any restrictions, but continued to have the Popeye deformity.

Our experience treating Mr. A serves as a reminder to physicians that complete long head biceps tendon rupture can be successfully treated conservatively. Patients working in sedentary occupations usually do not need a high degree of supination or physical strength in their upper extremities, making this a worthwhile treatment option for them.

CORRESPONDENCE 
Sofya Pugach, MD, PhD, MPH, Complete Med Care, 8989 Forest Lane, Dallas, TX 75243; Drpugach@yahoo.com

CASE A 29-year-old veteran (whom we’ll call Jane Doe) served as a medical corpsman in Iraq and has been pursuing a nursing degree since her honorable discharge a year ago. She comes in for a visit and reports a 3-month history of depression without suicidal ideation. In addition, Ms. Doe says, she has had abdominal pain that waxes and wanes for the past month. The pain is diffuse and nonfocal and appears to be unaffected by eating or bowel movements. She is unable to identify a particular pattern.

The patient has no significant medical or psychiatric history, and a physical examination is unremarkable. You advise her to follow a simplified dietary regimen, avoiding spicy foods and limiting dairy intake, and schedule a follow-up visit in 2 weeks.

Since 2002, some 2.4 million US troops have served in Iraq and Afghanistan,¹ creating a new generation of veterans who need broad-based support to recover from the physical and psychological wounds of war. All too often, those wounds include sexual assault or harassment, collectively known as military sexual trauma (MST).

MST is a growing concern for the Veterans Administration (VA) for a number of reasons—an increase in women on the front lines and greater media coverage of patterns of sexual assault in the military among them.² The official lifting of the ban on women in combat announced by the Pentagon in January brought the issue to the forefront, as well.³

In fact, MST should be a concern not only for clinicians within the VA, but also for civilian physicians. There are nearly 22 million American veterans, and the vast majority (>95%) get at least some of their medical care outside of the VA system⁴—often in outpatient facilities like yours.⁵ Family physicians need to be aware of the problem and able to give veterans who have suffered from sexual trauma the sensitive care they require.

The scope of the problem? No one is sure

How widespread is MST? That question is not easily answered. The prevalence rate among female service members is 20% to 43%,⁶ according to internal reports, while studies outside the military have reported rates that range from 3% to as high as 71%.⁵ In a recent anonymous survey of women in combat zones, led by a VA researcher—widely reported but still undergoing final review—half of those surveyed reported sexual harassment and nearly one in 4 reported sexual assault.⁷

There are far less data on rates of MST among male service members. The documented prevalence rate for men is 1.1%, with a range of 0.03% to 12.4%, but these figures are based on internal reports of sexual harassment and assault.⁸

Military culture and personal history are key factors
While the rate at which MST is reported has increased over the past 30 years,⁸ many reasons for not reporting it—stigma, fear of blame, accusations of homosexuality or promiscuity, and the threat of charges of fraternization among them—still remain.^8,9 Military culture is still male-dominated, with an emphasis on self-sufficiency that often leaves victims of MST feeling as though they have nowhere to turn.

There are also circumstances military members face that can aggravate the effects of sexual trauma. Soldiers on deployment are typically isolated from their normal support systems, under significant pressure, and unable to leave their post, which often means they have ongoing exposure to the abuser.

A history of childhood sexual abuse (CSA). As many as 50% of female service members (and about 17% of military men) have reported CSA,¹⁰ compared with 25% to 27% of women and 16% of men outside of the military.^5,11 That finding may be partially explained by data showing that nearly half of women in the military cited escaping from their home environment as a primary reason for enlisting.¹²

Women in the military who have a history of CSA, however, face a significantly higher risk for MST than servicewomen who were not sexually assaulted as children.⁸ Among female Navy recruits, for example, those who reported CSA were 4.8 times more likely to be raped than those who had no history of CSA.¹³

Combat-related trauma further complicates the picture. Evidence suggests that exposure to childhood physical and sexual abuse was associated with increased risk for combat-related posttraumatic stress disorder (PTSD) among men who served in Vietnam¹⁴ and women who served in Operation Desert Storm.¹⁵

Broaching the subject should be routine

Primary care physicians can play an important role in helping veterans transition back to their civilian lives and local communities, starting with a holistic medical assessment. When you see a patient whose return is relatively recent, inquire about his or her experiences during deployment. It is important to ask specifically about traumatic experiences, and to routinely screen for MST.

CASE When Ms. Doe returns. you begin by asking about her mood, using open-ended, nondirective questions. She responds by admitting that she had left important information off of the intake form she filled out on her last visit—most notably, a history of CSA. You gently ask about her experiences in the military, particularly during the year she spent in Iraq—and whether anything happened there that you should know.

Haltingly and with much emotion, the patient tells of her experience with another soldier. She worked with him every day, she says, and had grown close to him. One evening things went further than she expected. At first, it was only kissing, but then he forced himself on her sexually. She has not told anyone else about this event, Ms. Doe confides, because she wasn’t sure whether she precipitated it and felt embarrassed and humiliated by her choice to trust this man.

She did not feel that her supervising officers would listen or understand, as romantic attachments are best avoided in a combat zone and daily injuries are the norm. She says that her role as a medic kept her focused on the pain of others and enabled her to avoid looking at her own situation.

Evidence has shown that, like Ms. Doe, most survivors of trauma do not volunteer such information, but will often respond to direct and empathic questions from their physician.¹⁶ Routine screening of all veterans for MST, which the VA recommends, has been shown to increase their use of mental health resources.^17,18 This can be easily incorporated into a medical history or an intake questionnaire, using this simple 2-question tool:^17,18

While you were in the military:

• Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
• Did anyone ever use force or the threat of force to have sexual contact with you against your will?

Screen for PTSD, and consider other psychiatric disorders
MST has been found to confer a 9-fold risk for PTSD. Indeed, more than 4 in 10 (42%) women with a history of MST have a PTSD diagnosis.¹⁹ Thus, if the screen for MST is positive—as indicated by a Yes answer to either question—follow up with the 4-question Primary Care PTSD screen (TABLE 1) is recommended.²⁰

Veterans with a history of MST are twice as likely as other veterans to receive a mental health diagnosis;¹⁷ they’re also more likely to have 3 or more comorbid psychiatric conditions.²¹ Women appear to be more likely than men to suffer from depression, eating disorders, substance abuse,²² anxiety disorders,²¹ dissociative disorders, and personality disorders.¹⁷

Research on the mental health consequences of sexual assault in men (in any setting) is limited, however, and data on male survivors of MST are particularly sparse. What is known is that men who have experienced sexual trauma have higher rates of alcohol abuse²³ and self-harm²⁴ than women with a history of sexual trauma, and that MST has a greater association with bipolar disorder, schizophrenia, and psychosis in men.¹⁷

TABLE 1
Primary care PTSD screen (PC-PTSD)

Multiple physical symptoms are often trauma-related

Veterans with a history of MST are also more likely to report physical symptoms²⁵ and to have a lower health-related quality of life,²⁶ poorer health status, and more outpatient visits¹² than vets who were not exposed to MST. And, while pelvic pain is widely believed to be associated with female sexual abuse, survivors often present with a wide range of physical problems. The most common symptoms, similar to those affecting civilian rape survivors, include headache, gastrointestinal (GI) problems, chronic fatigue, severe menopause symptoms, and urological problems, as well as pelvic pain and sexual problems.²⁷ Cardiac and respiratory disorders are also common (TABLE 2).^17,25

Compared with their unaffected counterparts, women with a history of MST are more likely to be obese and sedentary, to smoke and drink, and to have had a hysterectomy before the age of 40 years.²⁸ They are also more than twice as likely as other female veterans to say that they were treated for a heart attack within the past year.²⁵ Data on the physical symptoms of male survivors of MST are extremely limited, but one study found an association with pulmonary and liver disease and human immunodeficiency virus and acquired immune deficiency syndrome.¹⁷

TABLE 2
Common physical symptoms reported by female MST survivors*^17,25

A cluster of nonspecific findings?
Patients with a history of MST often present with complex and nonspecific signs and symptoms, making it difficult for a primary care physician to arrive at a diagnosis. MST and combat-related trauma should be considered in such cases, as well as in veterans who present with complaints involving multiple organ systems.^21,25

Refer, treat—or do both

Once you have evidence that a patient is a survivor of MST, you need to consider a mental health referral or consultation and address physical symptoms. All honorably discharged veterans are eligible to receive VA treatment for MST, regardless of their disability rating or eligibility for other services. If a veteran indicates that he or she would like to seek psychotherapy or see a specialist outside of the VA system, it will fall to you to help the patient find the most appropriate treatment. (You’ll find links to VA and nonmilitary resources in the box.) Either way, patient acuity is a guide to the optimal approach.

Inpatient treatment will likely be needed for a patient who reveals thoughts of self-harm or harming others. If the patient is safe and stable enough for outpatient treatment, a therapist or psychiatrist with experience in treating sexual trauma is a good first step. Cognitive behavioral therapy and trauma-focused therapy have both been shown to have good outcomes in patients with sexual trauma and PTSD.²⁹ Depending on the individual’s key presenting issues, a consultation with a substance abuse specialist, gynecologist, or other specialist may be helpful, as well.

As a family physician, you are in a position to build a long-term, trusting relationship with such a patient, which may be therapeutic in itself.⁹ In building such a relationship, keep in mind that the experience of serving in the military could make a patient particularly sensitive, or resistant, to your advice; you’ll need to strive for a collaborative approach.

CASE You tell Ms. Doe that the incident she described was indeed sexual violence—and specifically known as military sexual trauma. Her feelings about it are likely surfacing now due to the time away from the military—and by the fact that she’s beginning to date. In addition to spending some time listening to her story, you advise Ms. Doe to start seeing a therapist. You suggest she consider VA treatment services, and direct her to its MST web site (www.mentalhealth.va.gov/msthome.asp). Before she leaves, you make it clear that you will continue to see and support her through this difficult time, and you schedule a follow-up visit.

CORRESPONDENCE 
Niranjan S. Karnik, MD, PhD, FAPA, University of Chicago, Pritzker School of Medicine, 5841 South Maryland, MC 3077, Chicago, IL 60637; nkarnik@bsd.uchicago.edu

CASE A 29-year-old veteran (whom we’ll call Jane Doe) served as a medical corpsman in Iraq and has been pursuing a nursing degree since her honorable discharge a year ago. She comes in for a visit and reports a 3-month history of depression without suicidal ideation. In addition, Ms. Doe says, she has had abdominal pain that waxes and wanes for the past month. The pain is diffuse and nonfocal and appears to be unaffected by eating or bowel movements. She is unable to identify a particular pattern.

The patient has no significant medical or psychiatric history, and a physical examination is unremarkable. You advise her to follow a simplified dietary regimen, avoiding spicy foods and limiting dairy intake, and schedule a follow-up visit in 2 weeks.

Since 2002, some 2.4 million US troops have served in Iraq and Afghanistan,¹ creating a new generation of veterans who need broad-based support to recover from the physical and psychological wounds of war. All too often, those wounds include sexual assault or harassment, collectively known as military sexual trauma (MST).

MST is a growing concern for the Veterans Administration (VA) for a number of reasons—an increase in women on the front lines and greater media coverage of patterns of sexual assault in the military among them.² The official lifting of the ban on women in combat announced by the Pentagon in January brought the issue to the forefront, as well.³

In fact, MST should be a concern not only for clinicians within the VA, but also for civilian physicians. There are nearly 22 million American veterans, and the vast majority (>95%) get at least some of their medical care outside of the VA system⁴—often in outpatient facilities like yours.⁵ Family physicians need to be aware of the problem and able to give veterans who have suffered from sexual trauma the sensitive care they require.

The scope of the problem? No one is sure

How widespread is MST? That question is not easily answered. The prevalence rate among female service members is 20% to 43%,⁶ according to internal reports, while studies outside the military have reported rates that range from 3% to as high as 71%.⁵ In a recent anonymous survey of women in combat zones, led by a VA researcher—widely reported but still undergoing final review—half of those surveyed reported sexual harassment and nearly one in 4 reported sexual assault.⁷

There are far less data on rates of MST among male service members. The documented prevalence rate for men is 1.1%, with a range of 0.03% to 12.4%, but these figures are based on internal reports of sexual harassment and assault.⁸

Military culture and personal history are key factors
While the rate at which MST is reported has increased over the past 30 years,⁸ many reasons for not reporting it—stigma, fear of blame, accusations of homosexuality or promiscuity, and the threat of charges of fraternization among them—still remain.^8,9 Military culture is still male-dominated, with an emphasis on self-sufficiency that often leaves victims of MST feeling as though they have nowhere to turn.

There are also circumstances military members face that can aggravate the effects of sexual trauma. Soldiers on deployment are typically isolated from their normal support systems, under significant pressure, and unable to leave their post, which often means they have ongoing exposure to the abuser.

A history of childhood sexual abuse (CSA). As many as 50% of female service members (and about 17% of military men) have reported CSA,¹⁰ compared with 25% to 27% of women and 16% of men outside of the military.^5,11 That finding may be partially explained by data showing that nearly half of women in the military cited escaping from their home environment as a primary reason for enlisting.¹²

Women in the military who have a history of CSA, however, face a significantly higher risk for MST than servicewomen who were not sexually assaulted as children.⁸ Among female Navy recruits, for example, those who reported CSA were 4.8 times more likely to be raped than those who had no history of CSA.¹³

Combat-related trauma further complicates the picture. Evidence suggests that exposure to childhood physical and sexual abuse was associated with increased risk for combat-related posttraumatic stress disorder (PTSD) among men who served in Vietnam¹⁴ and women who served in Operation Desert Storm.¹⁵

Broaching the subject should be routine

Primary care physicians can play an important role in helping veterans transition back to their civilian lives and local communities, starting with a holistic medical assessment. When you see a patient whose return is relatively recent, inquire about his or her experiences during deployment. It is important to ask specifically about traumatic experiences, and to routinely screen for MST.

CASE When Ms. Doe returns. you begin by asking about her mood, using open-ended, nondirective questions. She responds by admitting that she had left important information off of the intake form she filled out on her last visit—most notably, a history of CSA. You gently ask about her experiences in the military, particularly during the year she spent in Iraq—and whether anything happened there that you should know.

Haltingly and with much emotion, the patient tells of her experience with another soldier. She worked with him every day, she says, and had grown close to him. One evening things went further than she expected. At first, it was only kissing, but then he forced himself on her sexually. She has not told anyone else about this event, Ms. Doe confides, because she wasn’t sure whether she precipitated it and felt embarrassed and humiliated by her choice to trust this man.

She did not feel that her supervising officers would listen or understand, as romantic attachments are best avoided in a combat zone and daily injuries are the norm. She says that her role as a medic kept her focused on the pain of others and enabled her to avoid looking at her own situation.

Evidence has shown that, like Ms. Doe, most survivors of trauma do not volunteer such information, but will often respond to direct and empathic questions from their physician.¹⁶ Routine screening of all veterans for MST, which the VA recommends, has been shown to increase their use of mental health resources.^17,18 This can be easily incorporated into a medical history or an intake questionnaire, using this simple 2-question tool:^17,18

While you were in the military:

• Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
• Did anyone ever use force or the threat of force to have sexual contact with you against your will?

Screen for PTSD, and consider other psychiatric disorders
MST has been found to confer a 9-fold risk for PTSD. Indeed, more than 4 in 10 (42%) women with a history of MST have a PTSD diagnosis.¹⁹ Thus, if the screen for MST is positive—as indicated by a Yes answer to either question—follow up with the 4-question Primary Care PTSD screen (TABLE 1) is recommended.²⁰

Veterans with a history of MST are twice as likely as other veterans to receive a mental health diagnosis;¹⁷ they’re also more likely to have 3 or more comorbid psychiatric conditions.²¹ Women appear to be more likely than men to suffer from depression, eating disorders, substance abuse,²² anxiety disorders,²¹ dissociative disorders, and personality disorders.¹⁷

Research on the mental health consequences of sexual assault in men (in any setting) is limited, however, and data on male survivors of MST are particularly sparse. What is known is that men who have experienced sexual trauma have higher rates of alcohol abuse²³ and self-harm²⁴ than women with a history of sexual trauma, and that MST has a greater association with bipolar disorder, schizophrenia, and psychosis in men.¹⁷

TABLE 1
Primary care PTSD screen (PC-PTSD)

Multiple physical symptoms are often trauma-related

Veterans with a history of MST are also more likely to report physical symptoms²⁵ and to have a lower health-related quality of life,²⁶ poorer health status, and more outpatient visits¹² than vets who were not exposed to MST. And, while pelvic pain is widely believed to be associated with female sexual abuse, survivors often present with a wide range of physical problems. The most common symptoms, similar to those affecting civilian rape survivors, include headache, gastrointestinal (GI) problems, chronic fatigue, severe menopause symptoms, and urological problems, as well as pelvic pain and sexual problems.²⁷ Cardiac and respiratory disorders are also common (TABLE 2).^17,25

Compared with their unaffected counterparts, women with a history of MST are more likely to be obese and sedentary, to smoke and drink, and to have had a hysterectomy before the age of 40 years.²⁸ They are also more than twice as likely as other female veterans to say that they were treated for a heart attack within the past year.²⁵ Data on the physical symptoms of male survivors of MST are extremely limited, but one study found an association with pulmonary and liver disease and human immunodeficiency virus and acquired immune deficiency syndrome.¹⁷

TABLE 2
Common physical symptoms reported by female MST survivors*^17,25

A cluster of nonspecific findings?
Patients with a history of MST often present with complex and nonspecific signs and symptoms, making it difficult for a primary care physician to arrive at a diagnosis. MST and combat-related trauma should be considered in such cases, as well as in veterans who present with complaints involving multiple organ systems.^21,25

Refer, treat—or do both

Once you have evidence that a patient is a survivor of MST, you need to consider a mental health referral or consultation and address physical symptoms. All honorably discharged veterans are eligible to receive VA treatment for MST, regardless of their disability rating or eligibility for other services. If a veteran indicates that he or she would like to seek psychotherapy or see a specialist outside of the VA system, it will fall to you to help the patient find the most appropriate treatment. (You’ll find links to VA and nonmilitary resources in the box.) Either way, patient acuity is a guide to the optimal approach.

Inpatient treatment will likely be needed for a patient who reveals thoughts of self-harm or harming others. If the patient is safe and stable enough for outpatient treatment, a therapist or psychiatrist with experience in treating sexual trauma is a good first step. Cognitive behavioral therapy and trauma-focused therapy have both been shown to have good outcomes in patients with sexual trauma and PTSD.²⁹ Depending on the individual’s key presenting issues, a consultation with a substance abuse specialist, gynecologist, or other specialist may be helpful, as well.

As a family physician, you are in a position to build a long-term, trusting relationship with such a patient, which may be therapeutic in itself.⁹ In building such a relationship, keep in mind that the experience of serving in the military could make a patient particularly sensitive, or resistant, to your advice; you’ll need to strive for a collaborative approach.

CASE You tell Ms. Doe that the incident she described was indeed sexual violence—and specifically known as military sexual trauma. Her feelings about it are likely surfacing now due to the time away from the military—and by the fact that she’s beginning to date. In addition to spending some time listening to her story, you advise Ms. Doe to start seeing a therapist. You suggest she consider VA treatment services, and direct her to its MST web site (www.mentalhealth.va.gov/msthome.asp). Before she leaves, you make it clear that you will continue to see and support her through this difficult time, and you schedule a follow-up visit.

CORRESPONDENCE 
Niranjan S. Karnik, MD, PhD, FAPA, University of Chicago, Pritzker School of Medicine, 5841 South Maryland, MC 3077, Chicago, IL 60637; nkarnik@bsd.uchicago.edu

CASE A 29-year-old veteran (whom we’ll call Jane Doe) served as a medical corpsman in Iraq and has been pursuing a nursing degree since her honorable discharge a year ago. She comes in for a visit and reports a 3-month history of depression without suicidal ideation. In addition, Ms. Doe says, she has had abdominal pain that waxes and wanes for the past month. The pain is diffuse and nonfocal and appears to be unaffected by eating or bowel movements. She is unable to identify a particular pattern.

The patient has no significant medical or psychiatric history, and a physical examination is unremarkable. You advise her to follow a simplified dietary regimen, avoiding spicy foods and limiting dairy intake, and schedule a follow-up visit in 2 weeks.

Since 2002, some 2.4 million US troops have served in Iraq and Afghanistan,¹ creating a new generation of veterans who need broad-based support to recover from the physical and psychological wounds of war. All too often, those wounds include sexual assault or harassment, collectively known as military sexual trauma (MST).

MST is a growing concern for the Veterans Administration (VA) for a number of reasons—an increase in women on the front lines and greater media coverage of patterns of sexual assault in the military among them.² The official lifting of the ban on women in combat announced by the Pentagon in January brought the issue to the forefront, as well.³

In fact, MST should be a concern not only for clinicians within the VA, but also for civilian physicians. There are nearly 22 million American veterans, and the vast majority (>95%) get at least some of their medical care outside of the VA system⁴—often in outpatient facilities like yours.⁵ Family physicians need to be aware of the problem and able to give veterans who have suffered from sexual trauma the sensitive care they require.

The scope of the problem? No one is sure

How widespread is MST? That question is not easily answered. The prevalence rate among female service members is 20% to 43%,⁶ according to internal reports, while studies outside the military have reported rates that range from 3% to as high as 71%.⁵ In a recent anonymous survey of women in combat zones, led by a VA researcher—widely reported but still undergoing final review—half of those surveyed reported sexual harassment and nearly one in 4 reported sexual assault.⁷

There are far less data on rates of MST among male service members. The documented prevalence rate for men is 1.1%, with a range of 0.03% to 12.4%, but these figures are based on internal reports of sexual harassment and assault.⁸

Military culture and personal history are key factors
While the rate at which MST is reported has increased over the past 30 years,⁸ many reasons for not reporting it—stigma, fear of blame, accusations of homosexuality or promiscuity, and the threat of charges of fraternization among them—still remain.^8,9 Military culture is still male-dominated, with an emphasis on self-sufficiency that often leaves victims of MST feeling as though they have nowhere to turn.

There are also circumstances military members face that can aggravate the effects of sexual trauma. Soldiers on deployment are typically isolated from their normal support systems, under significant pressure, and unable to leave their post, which often means they have ongoing exposure to the abuser.

A history of childhood sexual abuse (CSA). As many as 50% of female service members (and about 17% of military men) have reported CSA,¹⁰ compared with 25% to 27% of women and 16% of men outside of the military.^5,11 That finding may be partially explained by data showing that nearly half of women in the military cited escaping from their home environment as a primary reason for enlisting.¹²

Women in the military who have a history of CSA, however, face a significantly higher risk for MST than servicewomen who were not sexually assaulted as children.⁸ Among female Navy recruits, for example, those who reported CSA were 4.8 times more likely to be raped than those who had no history of CSA.¹³

Combat-related trauma further complicates the picture. Evidence suggests that exposure to childhood physical and sexual abuse was associated with increased risk for combat-related posttraumatic stress disorder (PTSD) among men who served in Vietnam¹⁴ and women who served in Operation Desert Storm.¹⁵

Broaching the subject should be routine

Primary care physicians can play an important role in helping veterans transition back to their civilian lives and local communities, starting with a holistic medical assessment. When you see a patient whose return is relatively recent, inquire about his or her experiences during deployment. It is important to ask specifically about traumatic experiences, and to routinely screen for MST.

CASE When Ms. Doe returns. you begin by asking about her mood, using open-ended, nondirective questions. She responds by admitting that she had left important information off of the intake form she filled out on her last visit—most notably, a history of CSA. You gently ask about her experiences in the military, particularly during the year she spent in Iraq—and whether anything happened there that you should know.

Haltingly and with much emotion, the patient tells of her experience with another soldier. She worked with him every day, she says, and had grown close to him. One evening things went further than she expected. At first, it was only kissing, but then he forced himself on her sexually. She has not told anyone else about this event, Ms. Doe confides, because she wasn’t sure whether she precipitated it and felt embarrassed and humiliated by her choice to trust this man.

She did not feel that her supervising officers would listen or understand, as romantic attachments are best avoided in a combat zone and daily injuries are the norm. She says that her role as a medic kept her focused on the pain of others and enabled her to avoid looking at her own situation.

Evidence has shown that, like Ms. Doe, most survivors of trauma do not volunteer such information, but will often respond to direct and empathic questions from their physician.¹⁶ Routine screening of all veterans for MST, which the VA recommends, has been shown to increase their use of mental health resources.^17,18 This can be easily incorporated into a medical history or an intake questionnaire, using this simple 2-question tool:^17,18

While you were in the military:

• Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
• Did anyone ever use force or the threat of force to have sexual contact with you against your will?

Screen for PTSD, and consider other psychiatric disorders
MST has been found to confer a 9-fold risk for PTSD. Indeed, more than 4 in 10 (42%) women with a history of MST have a PTSD diagnosis.¹⁹ Thus, if the screen for MST is positive—as indicated by a Yes answer to either question—follow up with the 4-question Primary Care PTSD screen (TABLE 1) is recommended.²⁰

Veterans with a history of MST are twice as likely as other veterans to receive a mental health diagnosis;¹⁷ they’re also more likely to have 3 or more comorbid psychiatric conditions.²¹ Women appear to be more likely than men to suffer from depression, eating disorders, substance abuse,²² anxiety disorders,²¹ dissociative disorders, and personality disorders.¹⁷

Research on the mental health consequences of sexual assault in men (in any setting) is limited, however, and data on male survivors of MST are particularly sparse. What is known is that men who have experienced sexual trauma have higher rates of alcohol abuse²³ and self-harm²⁴ than women with a history of sexual trauma, and that MST has a greater association with bipolar disorder, schizophrenia, and psychosis in men.¹⁷

TABLE 1
Primary care PTSD screen (PC-PTSD)

Multiple physical symptoms are often trauma-related

Veterans with a history of MST are also more likely to report physical symptoms²⁵ and to have a lower health-related quality of life,²⁶ poorer health status, and more outpatient visits¹² than vets who were not exposed to MST. And, while pelvic pain is widely believed to be associated with female sexual abuse, survivors often present with a wide range of physical problems. The most common symptoms, similar to those affecting civilian rape survivors, include headache, gastrointestinal (GI) problems, chronic fatigue, severe menopause symptoms, and urological problems, as well as pelvic pain and sexual problems.²⁷ Cardiac and respiratory disorders are also common (TABLE 2).^17,25

Compared with their unaffected counterparts, women with a history of MST are more likely to be obese and sedentary, to smoke and drink, and to have had a hysterectomy before the age of 40 years.²⁸ They are also more than twice as likely as other female veterans to say that they were treated for a heart attack within the past year.²⁵ Data on the physical symptoms of male survivors of MST are extremely limited, but one study found an association with pulmonary and liver disease and human immunodeficiency virus and acquired immune deficiency syndrome.¹⁷

TABLE 2
Common physical symptoms reported by female MST survivors*^17,25

A cluster of nonspecific findings?
Patients with a history of MST often present with complex and nonspecific signs and symptoms, making it difficult for a primary care physician to arrive at a diagnosis. MST and combat-related trauma should be considered in such cases, as well as in veterans who present with complaints involving multiple organ systems.^21,25

Refer, treat—or do both

Once you have evidence that a patient is a survivor of MST, you need to consider a mental health referral or consultation and address physical symptoms. All honorably discharged veterans are eligible to receive VA treatment for MST, regardless of their disability rating or eligibility for other services. If a veteran indicates that he or she would like to seek psychotherapy or see a specialist outside of the VA system, it will fall to you to help the patient find the most appropriate treatment. (You’ll find links to VA and nonmilitary resources in the box.) Either way, patient acuity is a guide to the optimal approach.

Inpatient treatment will likely be needed for a patient who reveals thoughts of self-harm or harming others. If the patient is safe and stable enough for outpatient treatment, a therapist or psychiatrist with experience in treating sexual trauma is a good first step. Cognitive behavioral therapy and trauma-focused therapy have both been shown to have good outcomes in patients with sexual trauma and PTSD.²⁹ Depending on the individual’s key presenting issues, a consultation with a substance abuse specialist, gynecologist, or other specialist may be helpful, as well.

As a family physician, you are in a position to build a long-term, trusting relationship with such a patient, which may be therapeutic in itself.⁹ In building such a relationship, keep in mind that the experience of serving in the military could make a patient particularly sensitive, or resistant, to your advice; you’ll need to strive for a collaborative approach.

CASE You tell Ms. Doe that the incident she described was indeed sexual violence—and specifically known as military sexual trauma. Her feelings about it are likely surfacing now due to the time away from the military—and by the fact that she’s beginning to date. In addition to spending some time listening to her story, you advise Ms. Doe to start seeing a therapist. You suggest she consider VA treatment services, and direct her to its MST web site (www.mentalhealth.va.gov/msthome.asp). Before she leaves, you make it clear that you will continue to see and support her through this difficult time, and you schedule a follow-up visit.

CORRESPONDENCE 
Niranjan S. Karnik, MD, PhD, FAPA, University of Chicago, Pritzker School of Medicine, 5841 South Maryland, MC 3077, Chicago, IL 60637; nkarnik@bsd.uchicago.edu

Episodic heavy drinking, like alcoholism and drug addiction, is increasingly recognized as a medical problem that primary care physicians can, and should, address.¹ But it is rarely the chief reason for an office visit. Nor is it a subject patients are likely to bring up.

However, patients are generally willing to talk to a trusted doctor who asks about their use (or misuse) of alcohol or other substances. And primary care physicians can do much to help—with brief interventions, a growing armamentarium of pharmacotherapy, and referrals as needed. In the pages that follow, you’ll find easy-to-use screening tools and effective intervention strategies.

SCREENING NEEDN'T BE TIME-CONSUMING

Screening for substance use isn’t difficult. In fact, it can usually be accomplished with 2 targeted questions—one for alcohol use and one for drugs.

Alcohol. Two single-question screens to detect hazardous drinking have been validated, despite having different parameters. Ask either:

Q: When was the last time you had more than ____ drinks (4 for women and 5 for men) in one day?

Q: How many times in the past year have you had ___ or more drinks (4 for women and 5 for men) in one day?

For the first question, any answer within the past 3 months is a positive screen for hazardous drinking.² For the second, anything other than zero is positive.^3,4

Initial screening can also be done with the AUDIT-C (TABLE), a validated short (3-question) version of the Alcohol Use Disorders Identification Test that can be self-administered.^5,6

Drugs. Only one single-question screen for drug use has been validated:

Q: How many times in the past year have you used an illegal drug or taken a prescription medication for nonmedical reasons?

Any answer other than never is a positive screen for hazardous drug use.⁷

CASE Jason F, a healthy and fit 28-year-old, has been your patient, along with his family, for years. He’s in your office because of a knee injury he incurred while running, and you take a moment to ask him, for the first time, how much he drinks and whether he takes drugs. His answer—that he drinks 3 or 4 times a week and often has multiple drinks at parties or nights out with the guys—takes you a bit by surprise.

Now what?

Watch the video

TABLE

3-question AUDIT-C screen for alcohol dependence^5,6

TELL ME MORE ABOUT IT

It is important to respond to a positive screen by requesting more information. In the conversation that ensues, the patient may provide the details you need to determine whether the drinking or drug use is indicative of a diagnosable substance use disorder, an umbrella term for alcohol or drug abuse and alcohol or drug dependence.

Alcohol or drug abuse vs dependence. Criteria for alcohol or drug abuse in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) include risky behavior, such as drinking and driving; problems with work and/or close relationships; or run-ins with the law, such as an arrest for driving while intoxicated. Criteria for alcohol or drug dependence include the inability to cut down or stop using the substance; evidence of tolerance and withdrawal; spending more time ingesting the substance; increasing attention to substance use while interest in other activities diminishes; and continued use despite recurrent problems.⁸

Tools zero in on extent of problem

To learn more about your patient’s situation, consider using the following criteria and tools:

DSM criteria. Ask the following 2 questions, which are among DSM-IV-TR criteria for alcohol dependence:

1. How many times in the last year have you had a lot more to drink than you intended?
2. How many times in the last year have you been drinking in situations where it could have been hazardous, where you could have caused an accident or gotten hurt?

Any answer other than zero to either question is suggestive of a substance use disorder. In exploratory analyses, this approach had positive likelihood ratios of 4.7 to 16 and negative likelihood ratios of 0.05 to 0.30.^9,10

Although the above questions refer to alcohol use, they could be revised to learn more about a patient’s use of marijuana or other drugs, as well. (There are few tools for the assessment of drug use, because any illegal or nonmedical use of controlled substances has clear risks of major harm.)

CAGE. Another tool that is effective in assessing alcohol use is the 4-question CAGE—an acronym for Cut down, Annoyed, Guilty, and Eye opener:

• Have you ever felt that you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink in the morning to get rid of a hangover?

One meta-analysis found that a positive CAGE test—ie, a positive response to one or more of the questions—had a sensitivity of 0.85 and a specificity of 0.78 in identifying alcohol dependence in a primary care setting (using DSM criteria as the gold standard).¹¹

AUDIT. This 10-item tool, a longer version of the AUDIT-C (available at http://www.medstudentlearning.com/node/6556), can also be used to determine the extent of alcohol use. This test provides detailed information about the quantity and frequency of alcohol use; however, it does not clearly distinguish between hazardous drinking and alcohol use disorders.¹²

If the patient is a teen

Assessment methods can be adjusted without difficulty to fit the age of the patient. The National Institute on Alcohol Abuse and Alcoholism has published the Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide, available at http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/YouthGuide.aspx. The 6-question CRAFFT (for Car, Relax, Alone, Forget, Friends, Trouble) is a validated tool designed to assess adolescents’ use of both alcohol and drugs (http://www.ceasar-boston.org/clinicians/crafft.php).^13,14

CASE You give Mr. F the CAGE test, and he answers No to all 4 questions. You conclude that while his drinking may be hazardous, he does not appear to have alcohol abuse or dependence.

FOLLOW UP WITH A BRIEF INTERVENTION

For decades, evidence has shown that brief interventions are often effective in helping hazardous drinkers like Mr. F cut back to safer levels.^15-18 In some cases, the impact has been great enough to reduce health care and societal costs for up to 4 years¹⁹ and to cut the risk of alcohol-related death by about half.²⁰ As a result, the US Preventive Services Task Force has given a B rating to counseling to reduce alcohol misuse by primary care providers.²¹ (There is less evidence that brief interventions are effective for drug problems,²² or in settings other than primary care.²³)

Treat drug/alcohol problems

If you determine that your patient is engaging in hazardous alcohol or drug use or has a diagnosable substance use disorder, you do not have to drop everything else or treat it as an acute event. What matters is long-term success, which is best achieved by partnering with the patient.

Start by approaching drug and alcohol problems as you would a case of newly elevated blood pressure. Bring up the problem, seeking to engage the patient in addres- sing it.

If he or she does not agree to quit or cut back on drinking the first time you broach the subject, don’t be surprised or discouraged. Keep in mind that patients do not always respond positively to advice about handling chronic medical conditions either, particularly at first, and that you’ll be working together over time. What’s important, in the jargon of the Stages of Change model,²⁴ is to help the patient move from precontemplation to contemplation, and perhaps beyond that to planning or action.

Use motivational interviewing to partner with patients

Motivational interviewing is useful in helping patients change health-related behaviors. The technique, which is not hard to learn or apply, is based on the recognition that a simple shift in style toward a guiding (rather than directive) approach can often reap benefits that are immediately apparent. ^25-28

Motivational Interviewing: Helping People Change (3rd ed, by William R. Miller and Stephen Rollnick; Guilford Press, 2013) is an excellent resource for clinicians who wish to master this technique. An online tutorial in screening and brief intervention for alcohol or drug misuse is available free at https://adept.missouri.edu. Video demonstrations of motivational interviewing to address these issues are also available here ; to access them, click on “Training”, then on “Go to SBIRT videos”).

CASE Before Mr. F’s visit is concluded, you initiate a conversation about alcohol use, stating: “As your doctor, I’m concerned that the amount of alcohol you’re drinking could be hazardous to your health. I recommend that you cut down to no more than 4 drinks in any one day and to no more than 14 drinks a week.” You make it clear that change is up to him, and ask what he thinks about what you’ve said.

You also schedule a return visit in one month, at which time you will continue the conversation.

PHARMACOTHERAPY IS A USEFUL TOOL

Increasingly, alcohol and drug dependence—like other chronic conditions—can be effectively addressed with medication.

Drugs to treat alcohol dependence

Naltrexone. A daily dose of naltrexone, starting at 25 mg daily for a few days and going as high as 100 mg/d, can help patients with alcohol dependence limit their drinking to safe levels (number needed to treat [NNT]=9).²⁹ This will reduce the risk of alcohol-related harm while the patient considers quitting.

The most common adverse effect is nausea, but a low starting dose may alleviate it. Naltrexone, also available as a 380-mg intramuscular (IM) depot injection once every 4 weeks, is an opioid antagonist and should not be given to any patient who’s taking opioids.

A 2010 Cochrane review found only 4 trials of naltrexone IM, and failed to show significant reductions in drinking.²⁹ But post hoc analyses of trials of both oral and IM naltrexone found that those in which compliance was assured (either by direct observation or IM administration) had better outcomes than those in which it was not.³⁰ Another post hoc analysis found that patients whose alcohol dependence was more severe derived greater benefits from the drug than those who were less severely affected.³¹

Acamprosate. Two 333-mg pills tid can help newly abstinent drinkers remain alcohol-free (NNT=9).^32,33 The most common adverse effect is diarrhea, which may subside with continued use.

Combining acamprosate and naltrexone does not appear to be more effective than either drug alone. In a recently published meta-analysis comparing the 2 drugs, those taking acamprosate had slightly better rates of abstinence from alcohol, while naltrexone was slightly better in reducing heavy drinking.³⁴

Disulfiram Unlike naltrexone and acamprosate, which work by altering the brain’s reward circuits, disulfiram blocks metabolism of ethanol, leading to the accumulation of a toxic metabolite and its punishing syndrome. The major problem with the drug is noncompliance, which can be addressed by enlisting the help of a caregiver or partner to ensure that it is taken daily. ^35-37

Other medications that have been tested (though not approved by the US Food and Drug Administration [FDA]) as a treatment for alcohol dependence include:

• topiramate, which has been found to have modest efficacy in increasing the number of abstinent days and decreasing heavy-drinking days;³⁸
• baclofen, which has shown efficacy in small clinical trials;³⁹ and
• ondansetron, which has been shown to effectively treat early-onset alcohol dependence.^40,41

For patients with depression and alcohol dependence, the combination of naltrexone and sertraline has been found to be superior to either drug by itself—and to have fewer adverse effects. ⁴² Gabapentin and lorazepam have been compared in treating alcohol withdrawal, with gabapentin resulting in greater efficacy and fewer adverse effects than lorazepam.^43,44

Pharmacotherapy for drug abuse, dependence

For methamphetamine abuse and dependence. Two randomized clinical trials have studied medications for methamphetamine abuse and dependence. In one small study, topiramate did not increase the proportion of patients who achieved abstinence, but in a post hoc subgroup analysis, it did appear to help newly abstinent patients avoid relapse.⁴⁵

In another study, mirtazapine significantly decreased the proportion of patients whose weekly urine tests were positive for methamphetamine (from 73% to 44%); no significant change was found among those on placebo.⁴⁶

Both drugs were well tolerated, but compliance was low in both trials despite weekly counseling. Each has only one clinical trial to support its use, and neither has FDA approval for addiction treatment.

For marijuana dependence. In a study of 50 people seeking treatment for marijuana dependence, gabapentin 400 mg 3 times a day significantly improved the proportion reporting no cannabis use and whose urine tested negative for the drug.⁴⁷

Another recent trial randomized adolescents dependent on cannabis to placebo or N-acetylcysteine 1200 mg twice a day. Those on the active drug were 2.4 times more likely than those on placebo to have negative urine tests with a number needed to treat of 7.⁴⁸ Both trials ran for about 3 months. Neither drug is FDA approved to treat marijuana dependence.

For opioid dependence. As maintenance medication for patients dependent on opioids, both methadone and buprenorphine have been shown to reduce the use of illicit opioids, lower mortality, and improve retention compared with treatment without medication.⁴⁹ Methadone would be a better choice than buprenorphine, which is a partial agonist with a ceiling on both its good (eg, stopping craving) and bad (eg, overdose risk) effects. In an open-label observational study of patients’ preferences, those who chose methadone maintenance over buprenorphine were twice as likely to remain in treatment.⁵⁰ Both drugs are FDA-approved for treating opioid dependence.

Methadone is a full agonist that can be given for opioid dependence only in a federally licensed methadone maintenance clinic. It has been shown to reduce the use of other opioids, reduce criminal behaviors,⁵¹ improve function in many areas,⁵² and reduce mortality.⁵³ In a cohort study of Massachusetts Medicaid data, methadone reduced mortality, which was 75% higher among those receiving abstinence-based treatment.^52,54

Buprenorphine (alone and in combination with naloxone), effectively reduces the use of illicit opioids and improves functional status.^55-57

Naltrexone, an opioid antagonist, may be effective in the treatment of opioid dependence. As with disulfiram for alcohol dependence, a major limitation of naltrexone for opioid dependence is noncompliance. But once a patient has been on oral naltrexone, he or she can be switched to naltrexone IM, which can be administered every 4 weeks. A Cochrane review published in 2011 found no evidence that naltrexone was superior to placebo, ⁵⁸ but since then another randomized clinical trial has been published that found naltrexone 380 mg IM every 4 weeks was superior to IM placebo. Patients on naltrexone were more likely to remain in treatment and have opioid-free urine tests, and reported less craving for opioids.⁵⁹ Both oral and depot injection naltrexone are FDA approved for treatment of opioid dependence. No comparisons of naltrexone vs either methadone or buprenorphine have been published.

To learn more about pharmacotherapy for opioid dependence, see “Diagnosing and treating opioid dependence” (J Fam Pract. 2012;61:588-596).

DEALING WITH THE CHALLENGES

As noted earlier, some patients with substance use disorders, like some patients with depression or hypertension, respond well to care and counseling, and some do not. Just as with other conditions, consultation with a specialist often helps.

A major difference in arranging consultations for patients with substance use disorders, however, is that clinicians who specialize in substance abuse and dependence often work in health care systems that are largely, or entirely, separate from those in which primary care physicians typically work. This, plus the stigma that surrounds problems with substance use, presents barriers to patients, who may shy away from going across town or to another city to see a provider they don’t know for a problem they’re either resistant to “owning” or ashamed of.

Yet it is possible to reach across this divide and make it easier for patients. One way to do that might be to partner with a local alcohol- and drug-treatment program so that your patients are referred, not to a faceless agency, but rather to a specific clinician; you might even call the provider while the patient is in your office so they can “meet.” Another approach, taken by some multispecialty practices, is to add psychotherapists to the staff so that patients can simply walk down the hall to obtain the mental health care they need.

Reaching across this divide is also a useful strategy for primary care physicians, who may welcome opportunities to meet with someone from a local treatment agency, not just for referrals but to learn more about treating patients with substance use problems. The Patient Protection and Affordable Care Act, which cites substance use disorders as one of 6 chronic health conditions that primary care medical homes are expected to address, may lead to better integration of health care systems that address physical health, as well as mental health and substance use disorders.

CORRESPONDENCE 
Daniel C. Vinson, MD, MSPH, MA306E Health Sciences, Family and Community Medicine, University of Missouri, Columbia, MO 652312; vinsond@health.missouri.edu

Episodic heavy drinking, like alcoholism and drug addiction, is increasingly recognized as a medical problem that primary care physicians can, and should, address.¹ But it is rarely the chief reason for an office visit. Nor is it a subject patients are likely to bring up.

However, patients are generally willing to talk to a trusted doctor who asks about their use (or misuse) of alcohol or other substances. And primary care physicians can do much to help—with brief interventions, a growing armamentarium of pharmacotherapy, and referrals as needed. In the pages that follow, you’ll find easy-to-use screening tools and effective intervention strategies.

SCREENING NEEDN'T BE TIME-CONSUMING

Screening for substance use isn’t difficult. In fact, it can usually be accomplished with 2 targeted questions—one for alcohol use and one for drugs.

Alcohol. Two single-question screens to detect hazardous drinking have been validated, despite having different parameters. Ask either:

Q: When was the last time you had more than ____ drinks (4 for women and 5 for men) in one day?

Q: How many times in the past year have you had ___ or more drinks (4 for women and 5 for men) in one day?

For the first question, any answer within the past 3 months is a positive screen for hazardous drinking.² For the second, anything other than zero is positive.^3,4

Initial screening can also be done with the AUDIT-C (TABLE), a validated short (3-question) version of the Alcohol Use Disorders Identification Test that can be self-administered.^5,6

Drugs. Only one single-question screen for drug use has been validated:

Q: How many times in the past year have you used an illegal drug or taken a prescription medication for nonmedical reasons?

Any answer other than never is a positive screen for hazardous drug use.⁷

CASE Jason F, a healthy and fit 28-year-old, has been your patient, along with his family, for years. He’s in your office because of a knee injury he incurred while running, and you take a moment to ask him, for the first time, how much he drinks and whether he takes drugs. His answer—that he drinks 3 or 4 times a week and often has multiple drinks at parties or nights out with the guys—takes you a bit by surprise.

Now what?

Watch the video

TABLE

3-question AUDIT-C screen for alcohol dependence^5,6

TELL ME MORE ABOUT IT

It is important to respond to a positive screen by requesting more information. In the conversation that ensues, the patient may provide the details you need to determine whether the drinking or drug use is indicative of a diagnosable substance use disorder, an umbrella term for alcohol or drug abuse and alcohol or drug dependence.

Alcohol or drug abuse vs dependence. Criteria for alcohol or drug abuse in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) include risky behavior, such as drinking and driving; problems with work and/or close relationships; or run-ins with the law, such as an arrest for driving while intoxicated. Criteria for alcohol or drug dependence include the inability to cut down or stop using the substance; evidence of tolerance and withdrawal; spending more time ingesting the substance; increasing attention to substance use while interest in other activities diminishes; and continued use despite recurrent problems.⁸

Tools zero in on extent of problem

To learn more about your patient’s situation, consider using the following criteria and tools:

DSM criteria. Ask the following 2 questions, which are among DSM-IV-TR criteria for alcohol dependence:

1. How many times in the last year have you had a lot more to drink than you intended?
2. How many times in the last year have you been drinking in situations where it could have been hazardous, where you could have caused an accident or gotten hurt?

Any answer other than zero to either question is suggestive of a substance use disorder. In exploratory analyses, this approach had positive likelihood ratios of 4.7 to 16 and negative likelihood ratios of 0.05 to 0.30.^9,10

Although the above questions refer to alcohol use, they could be revised to learn more about a patient’s use of marijuana or other drugs, as well. (There are few tools for the assessment of drug use, because any illegal or nonmedical use of controlled substances has clear risks of major harm.)

CAGE. Another tool that is effective in assessing alcohol use is the 4-question CAGE—an acronym for Cut down, Annoyed, Guilty, and Eye opener:

• Have you ever felt that you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink in the morning to get rid of a hangover?

One meta-analysis found that a positive CAGE test—ie, a positive response to one or more of the questions—had a sensitivity of 0.85 and a specificity of 0.78 in identifying alcohol dependence in a primary care setting (using DSM criteria as the gold standard).¹¹

AUDIT. This 10-item tool, a longer version of the AUDIT-C (available at http://www.medstudentlearning.com/node/6556), can also be used to determine the extent of alcohol use. This test provides detailed information about the quantity and frequency of alcohol use; however, it does not clearly distinguish between hazardous drinking and alcohol use disorders.¹²

If the patient is a teen

Assessment methods can be adjusted without difficulty to fit the age of the patient. The National Institute on Alcohol Abuse and Alcoholism has published the Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide, available at http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/YouthGuide.aspx. The 6-question CRAFFT (for Car, Relax, Alone, Forget, Friends, Trouble) is a validated tool designed to assess adolescents’ use of both alcohol and drugs (http://www.ceasar-boston.org/clinicians/crafft.php).^13,14

CASE You give Mr. F the CAGE test, and he answers No to all 4 questions. You conclude that while his drinking may be hazardous, he does not appear to have alcohol abuse or dependence.

FOLLOW UP WITH A BRIEF INTERVENTION

For decades, evidence has shown that brief interventions are often effective in helping hazardous drinkers like Mr. F cut back to safer levels.^15-18 In some cases, the impact has been great enough to reduce health care and societal costs for up to 4 years¹⁹ and to cut the risk of alcohol-related death by about half.²⁰ As a result, the US Preventive Services Task Force has given a B rating to counseling to reduce alcohol misuse by primary care providers.²¹ (There is less evidence that brief interventions are effective for drug problems,²² or in settings other than primary care.²³)

Treat drug/alcohol problems

If you determine that your patient is engaging in hazardous alcohol or drug use or has a diagnosable substance use disorder, you do not have to drop everything else or treat it as an acute event. What matters is long-term success, which is best achieved by partnering with the patient.

Start by approaching drug and alcohol problems as you would a case of newly elevated blood pressure. Bring up the problem, seeking to engage the patient in addres- sing it.

If he or she does not agree to quit or cut back on drinking the first time you broach the subject, don’t be surprised or discouraged. Keep in mind that patients do not always respond positively to advice about handling chronic medical conditions either, particularly at first, and that you’ll be working together over time. What’s important, in the jargon of the Stages of Change model,²⁴ is to help the patient move from precontemplation to contemplation, and perhaps beyond that to planning or action.

Use motivational interviewing to partner with patients

Motivational interviewing is useful in helping patients change health-related behaviors. The technique, which is not hard to learn or apply, is based on the recognition that a simple shift in style toward a guiding (rather than directive) approach can often reap benefits that are immediately apparent. ^25-28

Motivational Interviewing: Helping People Change (3rd ed, by William R. Miller and Stephen Rollnick; Guilford Press, 2013) is an excellent resource for clinicians who wish to master this technique. An online tutorial in screening and brief intervention for alcohol or drug misuse is available free at https://adept.missouri.edu. Video demonstrations of motivational interviewing to address these issues are also available here ; to access them, click on “Training”, then on “Go to SBIRT videos”).

CASE Before Mr. F’s visit is concluded, you initiate a conversation about alcohol use, stating: “As your doctor, I’m concerned that the amount of alcohol you’re drinking could be hazardous to your health. I recommend that you cut down to no more than 4 drinks in any one day and to no more than 14 drinks a week.” You make it clear that change is up to him, and ask what he thinks about what you’ve said.

You also schedule a return visit in one month, at which time you will continue the conversation.

PHARMACOTHERAPY IS A USEFUL TOOL

Increasingly, alcohol and drug dependence—like other chronic conditions—can be effectively addressed with medication.

Drugs to treat alcohol dependence

Naltrexone. A daily dose of naltrexone, starting at 25 mg daily for a few days and going as high as 100 mg/d, can help patients with alcohol dependence limit their drinking to safe levels (number needed to treat [NNT]=9).²⁹ This will reduce the risk of alcohol-related harm while the patient considers quitting.

The most common adverse effect is nausea, but a low starting dose may alleviate it. Naltrexone, also available as a 380-mg intramuscular (IM) depot injection once every 4 weeks, is an opioid antagonist and should not be given to any patient who’s taking opioids.

A 2010 Cochrane review found only 4 trials of naltrexone IM, and failed to show significant reductions in drinking.²⁹ But post hoc analyses of trials of both oral and IM naltrexone found that those in which compliance was assured (either by direct observation or IM administration) had better outcomes than those in which it was not.³⁰ Another post hoc analysis found that patients whose alcohol dependence was more severe derived greater benefits from the drug than those who were less severely affected.³¹

Acamprosate. Two 333-mg pills tid can help newly abstinent drinkers remain alcohol-free (NNT=9).^32,33 The most common adverse effect is diarrhea, which may subside with continued use.

Combining acamprosate and naltrexone does not appear to be more effective than either drug alone. In a recently published meta-analysis comparing the 2 drugs, those taking acamprosate had slightly better rates of abstinence from alcohol, while naltrexone was slightly better in reducing heavy drinking.³⁴

Disulfiram Unlike naltrexone and acamprosate, which work by altering the brain’s reward circuits, disulfiram blocks metabolism of ethanol, leading to the accumulation of a toxic metabolite and its punishing syndrome. The major problem with the drug is noncompliance, which can be addressed by enlisting the help of a caregiver or partner to ensure that it is taken daily. ^35-37

Other medications that have been tested (though not approved by the US Food and Drug Administration [FDA]) as a treatment for alcohol dependence include:

• topiramate, which has been found to have modest efficacy in increasing the number of abstinent days and decreasing heavy-drinking days;³⁸
• baclofen, which has shown efficacy in small clinical trials;³⁹ and
• ondansetron, which has been shown to effectively treat early-onset alcohol dependence.^40,41

For patients with depression and alcohol dependence, the combination of naltrexone and sertraline has been found to be superior to either drug by itself—and to have fewer adverse effects. ⁴² Gabapentin and lorazepam have been compared in treating alcohol withdrawal, with gabapentin resulting in greater efficacy and fewer adverse effects than lorazepam.^43,44

Pharmacotherapy for drug abuse, dependence

For methamphetamine abuse and dependence. Two randomized clinical trials have studied medications for methamphetamine abuse and dependence. In one small study, topiramate did not increase the proportion of patients who achieved abstinence, but in a post hoc subgroup analysis, it did appear to help newly abstinent patients avoid relapse.⁴⁵

In another study, mirtazapine significantly decreased the proportion of patients whose weekly urine tests were positive for methamphetamine (from 73% to 44%); no significant change was found among those on placebo.⁴⁶

Both drugs were well tolerated, but compliance was low in both trials despite weekly counseling. Each has only one clinical trial to support its use, and neither has FDA approval for addiction treatment.

For marijuana dependence. In a study of 50 people seeking treatment for marijuana dependence, gabapentin 400 mg 3 times a day significantly improved the proportion reporting no cannabis use and whose urine tested negative for the drug.⁴⁷

Another recent trial randomized adolescents dependent on cannabis to placebo or N-acetylcysteine 1200 mg twice a day. Those on the active drug were 2.4 times more likely than those on placebo to have negative urine tests with a number needed to treat of 7.⁴⁸ Both trials ran for about 3 months. Neither drug is FDA approved to treat marijuana dependence.

For opioid dependence. As maintenance medication for patients dependent on opioids, both methadone and buprenorphine have been shown to reduce the use of illicit opioids, lower mortality, and improve retention compared with treatment without medication.⁴⁹ Methadone would be a better choice than buprenorphine, which is a partial agonist with a ceiling on both its good (eg, stopping craving) and bad (eg, overdose risk) effects. In an open-label observational study of patients’ preferences, those who chose methadone maintenance over buprenorphine were twice as likely to remain in treatment.⁵⁰ Both drugs are FDA-approved for treating opioid dependence.

Methadone is a full agonist that can be given for opioid dependence only in a federally licensed methadone maintenance clinic. It has been shown to reduce the use of other opioids, reduce criminal behaviors,⁵¹ improve function in many areas,⁵² and reduce mortality.⁵³ In a cohort study of Massachusetts Medicaid data, methadone reduced mortality, which was 75% higher among those receiving abstinence-based treatment.^52,54

Buprenorphine (alone and in combination with naloxone), effectively reduces the use of illicit opioids and improves functional status.^55-57

Naltrexone, an opioid antagonist, may be effective in the treatment of opioid dependence. As with disulfiram for alcohol dependence, a major limitation of naltrexone for opioid dependence is noncompliance. But once a patient has been on oral naltrexone, he or she can be switched to naltrexone IM, which can be administered every 4 weeks. A Cochrane review published in 2011 found no evidence that naltrexone was superior to placebo, ⁵⁸ but since then another randomized clinical trial has been published that found naltrexone 380 mg IM every 4 weeks was superior to IM placebo. Patients on naltrexone were more likely to remain in treatment and have opioid-free urine tests, and reported less craving for opioids.⁵⁹ Both oral and depot injection naltrexone are FDA approved for treatment of opioid dependence. No comparisons of naltrexone vs either methadone or buprenorphine have been published.

To learn more about pharmacotherapy for opioid dependence, see “Diagnosing and treating opioid dependence” (J Fam Pract. 2012;61:588-596).

DEALING WITH THE CHALLENGES

As noted earlier, some patients with substance use disorders, like some patients with depression or hypertension, respond well to care and counseling, and some do not. Just as with other conditions, consultation with a specialist often helps.

A major difference in arranging consultations for patients with substance use disorders, however, is that clinicians who specialize in substance abuse and dependence often work in health care systems that are largely, or entirely, separate from those in which primary care physicians typically work. This, plus the stigma that surrounds problems with substance use, presents barriers to patients, who may shy away from going across town or to another city to see a provider they don’t know for a problem they’re either resistant to “owning” or ashamed of.

Yet it is possible to reach across this divide and make it easier for patients. One way to do that might be to partner with a local alcohol- and drug-treatment program so that your patients are referred, not to a faceless agency, but rather to a specific clinician; you might even call the provider while the patient is in your office so they can “meet.” Another approach, taken by some multispecialty practices, is to add psychotherapists to the staff so that patients can simply walk down the hall to obtain the mental health care they need.

Reaching across this divide is also a useful strategy for primary care physicians, who may welcome opportunities to meet with someone from a local treatment agency, not just for referrals but to learn more about treating patients with substance use problems. The Patient Protection and Affordable Care Act, which cites substance use disorders as one of 6 chronic health conditions that primary care medical homes are expected to address, may lead to better integration of health care systems that address physical health, as well as mental health and substance use disorders.

CORRESPONDENCE 
Daniel C. Vinson, MD, MSPH, MA306E Health Sciences, Family and Community Medicine, University of Missouri, Columbia, MO 652312; vinsond@health.missouri.edu

Episodic heavy drinking, like alcoholism and drug addiction, is increasingly recognized as a medical problem that primary care physicians can, and should, address.¹ But it is rarely the chief reason for an office visit. Nor is it a subject patients are likely to bring up.

However, patients are generally willing to talk to a trusted doctor who asks about their use (or misuse) of alcohol or other substances. And primary care physicians can do much to help—with brief interventions, a growing armamentarium of pharmacotherapy, and referrals as needed. In the pages that follow, you’ll find easy-to-use screening tools and effective intervention strategies.

SCREENING NEEDN'T BE TIME-CONSUMING

Screening for substance use isn’t difficult. In fact, it can usually be accomplished with 2 targeted questions—one for alcohol use and one for drugs.

Alcohol. Two single-question screens to detect hazardous drinking have been validated, despite having different parameters. Ask either:

Q: When was the last time you had more than ____ drinks (4 for women and 5 for men) in one day?

Q: How many times in the past year have you had ___ or more drinks (4 for women and 5 for men) in one day?

For the first question, any answer within the past 3 months is a positive screen for hazardous drinking.² For the second, anything other than zero is positive.^3,4

Initial screening can also be done with the AUDIT-C (TABLE), a validated short (3-question) version of the Alcohol Use Disorders Identification Test that can be self-administered.^5,6

Drugs. Only one single-question screen for drug use has been validated:

Q: How many times in the past year have you used an illegal drug or taken a prescription medication for nonmedical reasons?

Any answer other than never is a positive screen for hazardous drug use.⁷

CASE Jason F, a healthy and fit 28-year-old, has been your patient, along with his family, for years. He’s in your office because of a knee injury he incurred while running, and you take a moment to ask him, for the first time, how much he drinks and whether he takes drugs. His answer—that he drinks 3 or 4 times a week and often has multiple drinks at parties or nights out with the guys—takes you a bit by surprise.

Now what?

Watch the video

TABLE

3-question AUDIT-C screen for alcohol dependence^5,6

TELL ME MORE ABOUT IT

It is important to respond to a positive screen by requesting more information. In the conversation that ensues, the patient may provide the details you need to determine whether the drinking or drug use is indicative of a diagnosable substance use disorder, an umbrella term for alcohol or drug abuse and alcohol or drug dependence.

Alcohol or drug abuse vs dependence. Criteria for alcohol or drug abuse in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) include risky behavior, such as drinking and driving; problems with work and/or close relationships; or run-ins with the law, such as an arrest for driving while intoxicated. Criteria for alcohol or drug dependence include the inability to cut down or stop using the substance; evidence of tolerance and withdrawal; spending more time ingesting the substance; increasing attention to substance use while interest in other activities diminishes; and continued use despite recurrent problems.⁸

Tools zero in on extent of problem

To learn more about your patient’s situation, consider using the following criteria and tools:

DSM criteria. Ask the following 2 questions, which are among DSM-IV-TR criteria for alcohol dependence:

1. How many times in the last year have you had a lot more to drink than you intended?
2. How many times in the last year have you been drinking in situations where it could have been hazardous, where you could have caused an accident or gotten hurt?

Any answer other than zero to either question is suggestive of a substance use disorder. In exploratory analyses, this approach had positive likelihood ratios of 4.7 to 16 and negative likelihood ratios of 0.05 to 0.30.^9,10

Although the above questions refer to alcohol use, they could be revised to learn more about a patient’s use of marijuana or other drugs, as well. (There are few tools for the assessment of drug use, because any illegal or nonmedical use of controlled substances has clear risks of major harm.)

CAGE. Another tool that is effective in assessing alcohol use is the 4-question CAGE—an acronym for Cut down, Annoyed, Guilty, and Eye opener:

• Have you ever felt that you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink in the morning to get rid of a hangover?

One meta-analysis found that a positive CAGE test—ie, a positive response to one or more of the questions—had a sensitivity of 0.85 and a specificity of 0.78 in identifying alcohol dependence in a primary care setting (using DSM criteria as the gold standard).¹¹

AUDIT. This 10-item tool, a longer version of the AUDIT-C (available at http://www.medstudentlearning.com/node/6556), can also be used to determine the extent of alcohol use. This test provides detailed information about the quantity and frequency of alcohol use; however, it does not clearly distinguish between hazardous drinking and alcohol use disorders.¹²

If the patient is a teen

Assessment methods can be adjusted without difficulty to fit the age of the patient. The National Institute on Alcohol Abuse and Alcoholism has published the Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide, available at http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/YouthGuide.aspx. The 6-question CRAFFT (for Car, Relax, Alone, Forget, Friends, Trouble) is a validated tool designed to assess adolescents’ use of both alcohol and drugs (http://www.ceasar-boston.org/clinicians/crafft.php).^13,14

CASE You give Mr. F the CAGE test, and he answers No to all 4 questions. You conclude that while his drinking may be hazardous, he does not appear to have alcohol abuse or dependence.

FOLLOW UP WITH A BRIEF INTERVENTION

For decades, evidence has shown that brief interventions are often effective in helping hazardous drinkers like Mr. F cut back to safer levels.^15-18 In some cases, the impact has been great enough to reduce health care and societal costs for up to 4 years¹⁹ and to cut the risk of alcohol-related death by about half.²⁰ As a result, the US Preventive Services Task Force has given a B rating to counseling to reduce alcohol misuse by primary care providers.²¹ (There is less evidence that brief interventions are effective for drug problems,²² or in settings other than primary care.²³)

Treat drug/alcohol problems

If you determine that your patient is engaging in hazardous alcohol or drug use or has a diagnosable substance use disorder, you do not have to drop everything else or treat it as an acute event. What matters is long-term success, which is best achieved by partnering with the patient.

Start by approaching drug and alcohol problems as you would a case of newly elevated blood pressure. Bring up the problem, seeking to engage the patient in addres- sing it.

If he or she does not agree to quit or cut back on drinking the first time you broach the subject, don’t be surprised or discouraged. Keep in mind that patients do not always respond positively to advice about handling chronic medical conditions either, particularly at first, and that you’ll be working together over time. What’s important, in the jargon of the Stages of Change model,²⁴ is to help the patient move from precontemplation to contemplation, and perhaps beyond that to planning or action.

Use motivational interviewing to partner with patients

Motivational interviewing is useful in helping patients change health-related behaviors. The technique, which is not hard to learn or apply, is based on the recognition that a simple shift in style toward a guiding (rather than directive) approach can often reap benefits that are immediately apparent. ^25-28

Motivational Interviewing: Helping People Change (3rd ed, by William R. Miller and Stephen Rollnick; Guilford Press, 2013) is an excellent resource for clinicians who wish to master this technique. An online tutorial in screening and brief intervention for alcohol or drug misuse is available free at https://adept.missouri.edu. Video demonstrations of motivational interviewing to address these issues are also available here ; to access them, click on “Training”, then on “Go to SBIRT videos”).

CASE Before Mr. F’s visit is concluded, you initiate a conversation about alcohol use, stating: “As your doctor, I’m concerned that the amount of alcohol you’re drinking could be hazardous to your health. I recommend that you cut down to no more than 4 drinks in any one day and to no more than 14 drinks a week.” You make it clear that change is up to him, and ask what he thinks about what you’ve said.

You also schedule a return visit in one month, at which time you will continue the conversation.

PHARMACOTHERAPY IS A USEFUL TOOL

Increasingly, alcohol and drug dependence—like other chronic conditions—can be effectively addressed with medication.

Drugs to treat alcohol dependence

Naltrexone. A daily dose of naltrexone, starting at 25 mg daily for a few days and going as high as 100 mg/d, can help patients with alcohol dependence limit their drinking to safe levels (number needed to treat [NNT]=9).²⁹ This will reduce the risk of alcohol-related harm while the patient considers quitting.

The most common adverse effect is nausea, but a low starting dose may alleviate it. Naltrexone, also available as a 380-mg intramuscular (IM) depot injection once every 4 weeks, is an opioid antagonist and should not be given to any patient who’s taking opioids.

A 2010 Cochrane review found only 4 trials of naltrexone IM, and failed to show significant reductions in drinking.²⁹ But post hoc analyses of trials of both oral and IM naltrexone found that those in which compliance was assured (either by direct observation or IM administration) had better outcomes than those in which it was not.³⁰ Another post hoc analysis found that patients whose alcohol dependence was more severe derived greater benefits from the drug than those who were less severely affected.³¹

Acamprosate. Two 333-mg pills tid can help newly abstinent drinkers remain alcohol-free (NNT=9).^32,33 The most common adverse effect is diarrhea, which may subside with continued use.

Combining acamprosate and naltrexone does not appear to be more effective than either drug alone. In a recently published meta-analysis comparing the 2 drugs, those taking acamprosate had slightly better rates of abstinence from alcohol, while naltrexone was slightly better in reducing heavy drinking.³⁴

Disulfiram Unlike naltrexone and acamprosate, which work by altering the brain’s reward circuits, disulfiram blocks metabolism of ethanol, leading to the accumulation of a toxic metabolite and its punishing syndrome. The major problem with the drug is noncompliance, which can be addressed by enlisting the help of a caregiver or partner to ensure that it is taken daily. ^35-37

Other medications that have been tested (though not approved by the US Food and Drug Administration [FDA]) as a treatment for alcohol dependence include:

• topiramate, which has been found to have modest efficacy in increasing the number of abstinent days and decreasing heavy-drinking days;³⁸
• baclofen, which has shown efficacy in small clinical trials;³⁹ and
• ondansetron, which has been shown to effectively treat early-onset alcohol dependence.^40,41

For patients with depression and alcohol dependence, the combination of naltrexone and sertraline has been found to be superior to either drug by itself—and to have fewer adverse effects. ⁴² Gabapentin and lorazepam have been compared in treating alcohol withdrawal, with gabapentin resulting in greater efficacy and fewer adverse effects than lorazepam.^43,44

Pharmacotherapy for drug abuse, dependence

For methamphetamine abuse and dependence. Two randomized clinical trials have studied medications for methamphetamine abuse and dependence. In one small study, topiramate did not increase the proportion of patients who achieved abstinence, but in a post hoc subgroup analysis, it did appear to help newly abstinent patients avoid relapse.⁴⁵

In another study, mirtazapine significantly decreased the proportion of patients whose weekly urine tests were positive for methamphetamine (from 73% to 44%); no significant change was found among those on placebo.⁴⁶

Both drugs were well tolerated, but compliance was low in both trials despite weekly counseling. Each has only one clinical trial to support its use, and neither has FDA approval for addiction treatment.

For marijuana dependence. In a study of 50 people seeking treatment for marijuana dependence, gabapentin 400 mg 3 times a day significantly improved the proportion reporting no cannabis use and whose urine tested negative for the drug.⁴⁷

Another recent trial randomized adolescents dependent on cannabis to placebo or N-acetylcysteine 1200 mg twice a day. Those on the active drug were 2.4 times more likely than those on placebo to have negative urine tests with a number needed to treat of 7.⁴⁸ Both trials ran for about 3 months. Neither drug is FDA approved to treat marijuana dependence.

For opioid dependence. As maintenance medication for patients dependent on opioids, both methadone and buprenorphine have been shown to reduce the use of illicit opioids, lower mortality, and improve retention compared with treatment without medication.⁴⁹ Methadone would be a better choice than buprenorphine, which is a partial agonist with a ceiling on both its good (eg, stopping craving) and bad (eg, overdose risk) effects. In an open-label observational study of patients’ preferences, those who chose methadone maintenance over buprenorphine were twice as likely to remain in treatment.⁵⁰ Both drugs are FDA-approved for treating opioid dependence.

Methadone is a full agonist that can be given for opioid dependence only in a federally licensed methadone maintenance clinic. It has been shown to reduce the use of other opioids, reduce criminal behaviors,⁵¹ improve function in many areas,⁵² and reduce mortality.⁵³ In a cohort study of Massachusetts Medicaid data, methadone reduced mortality, which was 75% higher among those receiving abstinence-based treatment.^52,54

Buprenorphine (alone and in combination with naloxone), effectively reduces the use of illicit opioids and improves functional status.^55-57

Naltrexone, an opioid antagonist, may be effective in the treatment of opioid dependence. As with disulfiram for alcohol dependence, a major limitation of naltrexone for opioid dependence is noncompliance. But once a patient has been on oral naltrexone, he or she can be switched to naltrexone IM, which can be administered every 4 weeks. A Cochrane review published in 2011 found no evidence that naltrexone was superior to placebo, ⁵⁸ but since then another randomized clinical trial has been published that found naltrexone 380 mg IM every 4 weeks was superior to IM placebo. Patients on naltrexone were more likely to remain in treatment and have opioid-free urine tests, and reported less craving for opioids.⁵⁹ Both oral and depot injection naltrexone are FDA approved for treatment of opioid dependence. No comparisons of naltrexone vs either methadone or buprenorphine have been published.

To learn more about pharmacotherapy for opioid dependence, see “Diagnosing and treating opioid dependence” (J Fam Pract. 2012;61:588-596).

DEALING WITH THE CHALLENGES

As noted earlier, some patients with substance use disorders, like some patients with depression or hypertension, respond well to care and counseling, and some do not. Just as with other conditions, consultation with a specialist often helps.

A major difference in arranging consultations for patients with substance use disorders, however, is that clinicians who specialize in substance abuse and dependence often work in health care systems that are largely, or entirely, separate from those in which primary care physicians typically work. This, plus the stigma that surrounds problems with substance use, presents barriers to patients, who may shy away from going across town or to another city to see a provider they don’t know for a problem they’re either resistant to “owning” or ashamed of.

Yet it is possible to reach across this divide and make it easier for patients. One way to do that might be to partner with a local alcohol- and drug-treatment program so that your patients are referred, not to a faceless agency, but rather to a specific clinician; you might even call the provider while the patient is in your office so they can “meet.” Another approach, taken by some multispecialty practices, is to add psychotherapists to the staff so that patients can simply walk down the hall to obtain the mental health care they need.

Reaching across this divide is also a useful strategy for primary care physicians, who may welcome opportunities to meet with someone from a local treatment agency, not just for referrals but to learn more about treating patients with substance use problems. The Patient Protection and Affordable Care Act, which cites substance use disorders as one of 6 chronic health conditions that primary care medical homes are expected to address, may lead to better integration of health care systems that address physical health, as well as mental health and substance use disorders.

CORRESPONDENCE 
Daniel C. Vinson, MD, MSPH, MA306E Health Sciences, Family and Community Medicine, University of Missouri, Columbia, MO 652312; vinsond@health.missouri.edu