A key focus of the family physician should be prevention of addictive disorders. Primary prevention involves helping at-risk individuals avoid the development of addictive behaviors. Secondary prevention consists of uncovering potentially harmful substance use prior to the onset of overt symptoms or problems. Finally, tertiary prevention involves treating the medical consequences of drug abuse and facilitating entry into treatment so further disability is minimized. Family physicians may also help prevent relapse, so that people who have been treated successfully are maintained in remission.
In family practice, primary prevention should be directed at children and adolescents at risk. A good approach is to emphasize the realistic risks of drug and alcohol abuse; this can provide an understanding of the problem. The physician should also support any reluctance the child expresses about giving in to peer pressure to smoke or drink.
There seems to be an association between domestic violence and substance abuse. Children who have been physically or sexually abused are at very high risk for substance abuse as adults . Increased risk is also seen in children of substance-abusing parents and in children with attention-deficit disorder or school problems such as a developmental reading disorder. Preventive interventions may include the usual child protection and referral activities, plus an explanation of the consequences of smoking and substance abuse, preferably at a point when the child is receptive to such information but is not yet being pressed by peers to join them in such activities.
Programs such as the Students Taught Awareness and Resistance (STAR) program, in which schoolchildren are taught skills to avoid high-risk activities, or the Strengthening Families program for drug-abusing parents and their children may also be beneficial. The effectiveness of any existing prevention programs in the school or community can be markedly improved by reinforcement from the physician. Bonding with a stable, caring adult may be the most important protective factor for high-risk children.
For family physicians who want to utilize a validated method of screening for drug abuse as well as developmental risk factors in children, the Problem Oriented Screening Instrument for Teenagers (POSIT) is available through the National Clearinghouse for Alcohol and Drug Abuse Information .
Nicotine addiction, which is generally the first addiction to occur in children, appears to develop over a two-year period. This presents a window of opportunity when intervention may be particularly effective. Adolescent males who are active in sports should also be targeted for inquiry about their use of anabolic steroids, with special attention paid to sports that require weight and strength, such as football.
Primary prevention may also be needed for an adult patient who the physician realizes is entering a risky situation - e.g., a close relationship with a person who abuses alcohol or drugs. With women of childbearing age, it is crucial to emphasize the extreme risks associated with substance abuse during pregnancy. This may involve encouraging use of effective birth control for a woman who insists on drinking or smoking and intensive counseling about the risks of substance abuse (including the risk for HIV and other infectious disease) during pregnancy for women who intend to become or are pregnant. Women suffering from postpartum depression should be warned about the dangers of self-treatment with alcohol or stimulants. Many other psychiatric disorders such as panic attacks increase the risk for substance abuse unless diagnosed and treated appropriately.
Secondary and Relapse Prevention
Maintaining alertness for early signs of drug abuse or a history suggestive of drug abuse is the main way that physicians can detect the early stages of disease or relapse. Because addiction is a chronic relapsing disorder , the person in recovery from addiction remains at risk for relapse or for developing problems with another substance. This is less likely for successful patients still in methadone maintenance than for patients who are completely drug-free. However, some patients on methadone maintenance do abuse multiple drugs, especially if the prescribed dose of methadone is too low.
If at all possible, use of benzodiazepines should be avoided in patients with any substance abuse history; if not, only small amounts (with no refills) for a short course of therapy should be provided. Remember, however, that recovering addicts may have legitimate physical conditions that require opiate analgesics for pain management or may have other legitimate indications for psychotropic medications. Withholding such indicated treatment may cause an even greater risk for relapse than giving an appropriate prescription for controlled amounts of opiates. When in doubt, it is best (with the patient's permission) to contact the program where he or she is being treated or consult with another physician experienced in the treatment of pain, addiction and mental disorders.
Although specialized group therapy approaches to relapse prevention are becoming more available, the most common means of relapse prevention for the family physician will probably continue to be frequent monitoring and counseling, plus environmental and family encouragement of abstinence. It is important to keep track of patients with addictive disorders and to discuss their progress in recovery during clinical visits for unrelated issues. Changes in the patient's life may jeopardize their sobriety, and new temptations may emerge; it may become necessary to recommend additional counseling at such times.