An 18-year-old man comes to the office for a follow-up visit. He was seen in the emergency department 3 months ago because of panic attacks related to cocaine use. The patient subsequently stopped using cocaine and has had no recurrent anxiety symptoms. He graduated from high school, started a new job, and has been considering applying to community college. At today's visit, the patient reports that he used cocaine at a friend's house this past weekend. He says, "I really messed up. I feel like a failure." The patient has no history of illness. He is in no physical discomfort. Which of the following is the most appropriate statement by the physician at this time?

Question

An 18-year-old man comes to the office for a follow-up visit.  He was seen in the emergency department 3 months ago because of panic attacks related to cocaine use.  The patient subsequently stopped using cocaine and has had no recurrent anxiety symptoms.  He graduated from high school, started a new job, and has been considering applying to community college.  At today's visit, the patient reports that he used cocaine at a friend's house this past weekend.  He says, "I really messed up.  I feel like a failure."  The patient has no history of illness.  He is in no physical discomfort.  Which of the following is the most appropriate statement by the physician at this time?

Quizplus · Accepted Answer

11ec160b_3665_df8a_9249_b7416d25df33_MD0001_00 This patient says he feels "like a failure" because he used cocaine again following a 3-month period of abstinence. Focusing on the negative consequences of cocaine use (which the patient is already aware of) may be perceived as shaming and judgmental. The best approach is to help the patient feel understood by acknowledging his feelings of disappointment but reframing his relapse as a temporary setback he can surmount. Principles of motivational interviewing can be used to help this patient get back on track and strengthen his belief that he can keep making progress. Motivational interviewing is a nonjudgmental, collaborative, patient-centered approach that enhances the patient's sense of self-confidence and self-efficacy. By emphasizing the patient's past success in maintaining abstinence for a period of time, the physician supports the patient's belief in his ability to learn from this setback and make changes. Open-ended discussion of what contributed to using cocaine again from the patient's perspective can then be used to guide the patient to make a specific plan to achieve and implement change. (Choice A) This question has a judgmental tone and fails to acknowledge how the patient feels. It also assumes the patient will keep using and prematurely focuses on possible negative consequences of continued use. (Choice B) This approach also focuses on reiterating the negative health effects of cocaine rather than addressing the patient's loss of confidence in his ability to make changes. Focusing on his strengths rather than on negative consequences is more likely to build internal motivation. (Choice C) Although this statement seems supportive, it discourages self-reflection and does not help build the patient's sense of self-efficacy. (Choice D) Rather than first exploring the patient's own thoughts about his relapse, this approach is assumptive and reflects a desire to control the agenda while rushing to a premature solution. Such a statement misses the opportunity to elicit the patient's perspective and help build his confidence in his own ability to make changes. Educational objective: Principles of motivational interviewing can be used in the treatment of substance use disorders to guide responses to patients who relapse. This technique helps build patients' sense of self-efficacy by emphasizing their past successes in maintaining abstinence and by supporting patients' belief in their ability to make changes.

An 18-Year-Old Man Comes to the Office for a Follow-Up