A 22-year-old man is found unresponsive on his bedroom floor. His girlfriend calls emergency medical services, and paramedics arrive within 10 minutes. She says that the patient has been using heroin and points to track marks on his right arm. Temperature is 37.8 C (100 F), blood pressure is 90/40 mm Hg, pulse is 65/min, and respirations are 6/min. The paramedics provide supportive care and administer naloxone on the way to the hospital. The patient's condition stabilizes in the emergency department. The toxicology screen is positive for opiates and cannabis. Once he becomes more alert, additional information, including a substance abuse history, is obtained. The patient says, "I've been using heroin for the last 9 months and drinking since I was 16. I like to use pretty much any drug I can get my hands on; I don't see what the big deal is." He has never tried to stop using and has never been to a drug-detoxification or drug-rehabilitation program. He recently lost his construction job as he was "too high to show up." His girlfriend is considering leaving him if he does not get help.
Which of the following statements or questions is the most appropriate for initiating a discussion about the patient's substance use?

Question

A 22-year-old man is found unresponsive on his bedroom floor.  His girlfriend calls emergency medical services, and paramedics arrive within 10 minutes.  She says that the patient has been using heroin and points to track marks on his right arm.  Temperature is 37.8 C (100 F), blood pressure is 90/40 mm Hg, pulse is 65/min, and respirations are 6/min.  The paramedics provide supportive care and administer naloxone on the way to the hospital.  The patient's condition stabilizes in the emergency department.  The toxicology screen is positive for opiates and cannabis.  Once he becomes more alert, additional information, including a substance abuse history, is obtained.  The patient says, "I've been using heroin for the last 9 months and drinking since I was 16.  I like to use pretty much any drug I can get my hands on; I don't see what the big deal is."  He has never tried to stop using and has never been to a drug-detoxification or drug-rehabilitation program.  He recently lost his construction job as he was "too high to show up."  His girlfriend is considering leaving him if he does not get help. 
Which of the following statements or questions is the most appropriate for initiating a discussion about the patient's substance use?

Quizplus · Accepted Answer

Explanation: The psychotherapeutic technique of motivational interviewing is used to encourage patients to change maladaptive behaviors. Interventions are geared to the patient's stage of readiness to change. Elements include a nonjudgmental stance, focusing on the patient's intrinsic motivation to change, acknowledging ambivalence and resistance to change, and supporting the patient's efforts to take responsibility for recovery. The patient should not be pressured with threats about negative consequences, guilt, and shame as these are not helpful. 11ec2b69_c1a9_48bc_8f63_b1ed645b9c1d_MD0005_00 This patient has a substance use disorder with severe medical and psychosocial consequences but shows no indication of wanting to change his behavior at this time (precontemplation stage). To have an impact, the physician's initial approach must take this into account. Encouraging the patient to evaluate his behavior and its consequences would be the most appropriate initial approach. (Choice A) Recommending a substance abuse rehabilitation program at this time is premature. It would be appropriate after the patient recognizes the consequences and shows some intrinsic motivation to change. (Choices B and E) Motivational interviewing emphasizes development of the patient's intrinsic motivation to change and take responsibility for recovery. Threatening patients with negative consequences or attempting to elicit guilt is not recommended. (Choice C) This patient has indicated that he has no intention of stopping his drug use. Questions about relapse prevention are premature and more appropriate in the maintenance stage, when the patient has integrated changes and is focused on preventing relapse. Educational objective: Patients who are not ready to change or are unaware of negative consequences of substance use should be educated in a nonthreatening manner about the risks and encouraged to evaluate the pros and cons of continued use. References: Motivational interviewing for substance abuse. (http://www.ncbi.nlm.nih.gov/pubmed/21563163) Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. (http://www.ncbi.nlm.nih.gov/pubmed/21728400)

A 22-Year-Old Man Is Found Unresponsive on His Bedroom Floor