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.At 1-month follow-up, the patient says that he was recently arrested and charged with driving under the influence. His court date is set for later in the month. The patient confirms that he was intoxicated at the time and is worried about sentencing. He tells the physician that his girlfriend has left him and that it has been a struggle finding work. He says, "I can't blame her for leaving. I stopped for a week but started using again after getting fired from yet another job. I'm a pretty good worker, but I think the boss could tell I was using. It's the people I hang out with; it's hard to stop when they're all getting high."
Which of the following is the best indicator of this patient's motivation to change his behavior?

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.At 1-month follow-up, the patient says that he was recently arrested and charged with driving under the influence.  His court date is set for later in the month.  The patient confirms that he was intoxicated at the time and is worried about sentencing.  He tells the physician that his girlfriend has left him and that it has been a struggle finding work.  He says, "I can't blame her for leaving.  I stopped for a week but started using again after getting fired from yet another job.  I'm a pretty good worker, but I think the boss could tell I was using.  It's the people I hang out with; it's hard to stop when they're all getting high." 
Which of the following is the best indicator of this patient's motivation to change his behavior?

Quizplus · Accepted Answer

Explanation: The patient is now able to recognize some of the negative consequences of his substance use (eg, not blaming his girlfriend for leaving, acknowledging that it is likely the reason he was fired, legal consequences). However, awareness of negative consequences is characteristic of the contemplation stage in which the patient thinks about changing but has not taken any steps to do so. Even though the patient was unsuccessful, his effort at sobriety indicates that he had moved into the action phase of change, taking concrete steps to alter his behavior. The physician should validate that the week of sobriety was a major step in the right direction, explaining that relapse is a common part of the cycle and reinforcing the patient's intrinsic motivation to take further action. (Choices A and E) Awareness of the negative consequences of continued substance use is characteristic of the contemplation stage, in which the patient thinks about changing. His effort to stop using indicates that he has gone beyond the stage of thinking about change and has taken steps to stop using. (Choice B) This statement shows awareness of a trigger for substance use but does not indicate that the patient takes personal responsibility for his behavior or has taken any steps to decrease his interactions with other drug users. (Choice C) The patient's concern about his arrest for driving under the influence is due to his fear of legal punishment and does not indicate any intrinsic motivation to change. Educational objective: Once the patient takes initial steps to change behavior, a physician should support the patient's intrinsic motivation to take further action in that direction. References: The effects of motivational interviewing on patients with comorbid substance use admitted to a psychiatric emergency unit - a randomised controlled trial with two year follow-up. (http://www.ncbi.nlm.nih.gov/pubmed/23517244)

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