Case Eight: Spouses of Drug Users


Tom is a 16 year old who comes to you for a physical because he wants to try out for the soccer team. When you ask about stress in his life, he notes that he parents are always fighting, and this upsets him.

He believes that they fight more when they have been drinking, and he believes that his father is the heavier drinker of the two, but he cannot quantify either parent's use.

Questions For Health Care Professionals

A. How would you approach the patient (either cooperative or resistant)?

(The goal is to develop a positive, non-judgemental rapport with the patient.)

  1. Use your rapport.

  2. Don't be afraid to explore the issue.

  3. Display compassion and concern.

  4. Ensure confidentiality

  5. Use a neutral, matter of fact, tone of voice

  6. Acknowledge it may be difficult for the patient to share this information.

  7. Be nonjudgmental. The more nonjudgmental you are the more likely the patient is to reveal information.]

  8. Be redundant. If your questions are not being completely answered ask again.

  9. Phrase the question appropriately. For example, ask, "Tell me about your partner's marijuana use," instead of "Do they smoke pot?" (Avoid the term "illegal drugs".)

B. What data do you need to collect or what initial screening should be done? 

(The goal is to gather relevant history and barrier information.)

  1. Assess the environmental risks as well as how the patient is coping with his situation.
  • a. How often during the day does your partner smoke marijuana?

  • b. How long has your partner been engaging in this behavior?

  • c. Is there any physical or verbal abuse in the home

  • d. Have you talked to your partner about this? What was the response?

  • e. Do you ever feel frightened or unsafe in the home?

  • f. What do you do when your partner smokes marijuana?

  • g. Tell me about your marijuana use?

  • h. Does your partner smoke marijuana while the children are present?

  • i. Do you have concerns about your partner's alcohol use or any other drug use?

  • k. Do you know if your partner has ever been in treatment for drug or alcohol use?

If she starts to become resistant or uncooperative try to reassure the patient that you are gathering this information to ensure that she is okay.

C. What other medications/drugs is the patient using?

  1. Review the patient's medication. Be alert to a history of physical injuries, that given this new information, may be attributed to violence in the home.

  2. Review patient's history of alcohol and other drug use.

D. What is the pattern of patient's medication/drug use?

(The goal is to determine when, how often, and under what kind of stress/pain conditions is the patient using/abusing the prescribed medications or other drugs.)

E. What internal/external obstacles and biases might the patient face?

(The goal is to determine how receptive/resistant the client will be to a discussion regarding her family situation. The physician needs to be aware of the internal/external stigma and biases that the patient faces. The physician will need this information to determine how best to approach the patient and/or his parents).

  1. Fear of getting into trouble with her partner.

  2. Fear of getting her partner into trouble.

  3. Embarrassment and shame

  4. Fear of rejection by friends or culture

  5. The patient's belief that this is normal

  6. Lack of insurance for treatment

  7. Transportation

  8. Fear of legal ramifications if they feel they are divulging sensitive information

F. What internal/external obstacles and biases might the physician face?

  1. Belief that addiction is a moral issue and not a medical issue

  2. Lack of treatment availability (affordability, waiting-lists, services not available in community)

  3. Physician's discomfort with addressing substance abuse issues

  4. Physician own history of marijuana use.

  5. Time constraints

  6. Physician's family history causes countertransference (misperceptions based on personal experiences).

G. What do you do now?

(This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)

  1. Discuss evidence for concern (patient's own concern as well as any alarming information you've obtained)

  2. Display compassion

  3. Provide reassurance that there is help available

  4. Ask the patient whether she would like additional support to help her with this issue.

  5. Assess the need for a referral to DCFS

  6. Address the stigma associated with having a partner who has a substance abuse problem

H. How does the physician make a referral?

If it is clear that there is concern regarding the patient's home environment and her ability to cope with any resulting stress, a referral should be made.

  1. Explore possibilities for support and/or counseling, such as Alanon, Families Anonymous, or a private practitioner. Provide any necessary referral and consider patient's health insurance coverage.

  2. Encourage the patient to develop healthy boundaries and a broad support network.

I. When and how should the physician follow up with the patient? 

  1. Physician should ask the patient if they followed up with their referral and discuss resulting actions.

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