A 22-year-old man comes to the clinic for routine follow-up of his mild asthma. He has a history of keeping his appointments but has missed the last three. Today he seems distracted and uninterested, answering various questions with very brief replies. At one point, the patient says that he would like to hurry the visit along so he can get home sooner. Following inquiries about his social life, he becomes more animated and describes spending time with new friends who "really know how to party." On further questioning, he says, "I have been snorting cocaine sometimes but it's not a big deal. I haven't used any this past week. I quit school because it was just stupid and I was wasting my money. I'm working as a waiter now and enjoying it. At least I can make my own money and not be dependent on my parents." The patient says that he has been living with his new friends since his parents asked him to move out 2 weeks ago, but he would "rather not talk about that." He denies any symptoms of depression, mania, or psychosis. Temperature is 37.7 C (99.9 F), blood pressure is 120/82 mm Hg, pulse is 86/min, and respirations are 15/min. Physical examination shows perforations of the nasal septum.
Which of the following is the most appropriate next step in management of this patient?

Question

A 22-year-old man comes to the clinic for routine follow-up of his mild asthma.  He has a history of keeping his appointments but has missed the last three.  Today he seems distracted and uninterested, answering various questions with very brief replies.  At one point, the patient says that he would like to hurry the visit along so he can get home sooner.  Following inquiries about his social life, he becomes more animated and describes spending time with new friends who "really know how to party."  On further questioning, he says, "I have been snorting cocaine sometimes but it's not a big deal.  I haven't used any this past week.  I quit school because it was just stupid and I was wasting my money.  I'm working as a waiter now and enjoying it.  At least I can make my own money and not be dependent on my parents."  The patient says that he has been living with his new friends since his parents asked him to move out 2 weeks ago, but he would "rather not talk about that."  He denies any symptoms of depression, mania, or psychosis.  Temperature is 37.7 C (99.9 F), blood pressure is 120/82 mm Hg, pulse is 86/min, and respirations are 15/min.  Physical examination shows perforations of the nasal septum. 
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's change in behavior and physical examination finding of septal perforation suggest a cocaine problem. When substance abuse presents in the primary care setting, the physician should take a comprehensive history (amount, frequency, route of administration, date of last use, perceived benefits, and negative consequences) and perform a non-judgmental, brief counseling intervention. Components of such an intervention include initially engaging the patient in a discussion, educating the patient about the personal risks of substance use, developing collaborative goals for reducing use, and openly discussing treatment options. An empathic, nonjudgmental approach with emphasis on patient autonomy and self-efficacy are critical to developing a treatment alliance. The diagnosis of cocaine use disorder is based on the patient's history and collateral sources (if obtainable with the patient's permission). A urine drug test would confirm only recent cocaine use (2-3 days). Because the patient has already admitted to cocaine use, it would be more productive and less costly to ask additional screening questions to clarify the extent of use and whether he is using other substances. (Choices A and E) This patient appears disengaged with the physician and does not view his cocaine use as problematic. At this stage (pre-contemplation), he would likely be unreceptive to recommendations to attend a 12-step mutual help group or drug counseling. The first step is to engage the patient in a collaborative discussion of the perceived benefits and consequences of his drug use. (Choice B) Although this patient should be informed about his perforated septum, it is important to engage him in an open-ended discussion of his substance use. Telling him that he should abstain without his input would be perceived as authoritarian and judgmental and is unlikely to be beneficial. A brief counseling intervention that fosters autonomy and collaborative decision-making is more likely to lead to internal motivation to change. (Choice C) A positive urine toxicology screen would confirm cocaine use and identify other drugs being used. However, it would detect only recent use and would not change management of the patient. Urine drug screens can be helpful when the clinical picture is uncertain or when patients are receiving prescribed controlled substances and need monitoring to prevent diversion or combination with other substances. Educational objective: Taking a thorough history can effectively identify substance abuse in the primary care setting. Once it is identified, the initial approach consists of engaging the patient in a brief counseling session to discuss personal risk and develop collaborative goals and a treatment plan. References: Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. (http://www.ncbi.nlm.nih.gov/pubmed/23210379)

A 22-Year-Old Man Comes to the Clinic for Routine Follow-Up