The day Kim LaMontagne decided she needed help with her drinking, she got in touch with her primary care doctor just before 5 p.m. She assumed she’d get an appointment with him the next day. That way, she could go home and enjoy one last bottle of wine.
But that’s not what happened. Instead, LaMontagne ended up seeing a nurse practitioner that day. Within the hour, she was sitting in an exam room, tearfully laying out her situation: She was a successful professional, drowning in shame over depression, anxiety and binge drinking. The nurse practitioner listened to her carefully, and responded in exactly the right way.
“He looked me straight in the eye and said, ‘Kim, I’m going to help you,’” recalls LaMontagne, now 48. “He had zero judgement at all.”
Ten years later, he’s the person LaMontagne credits with helping to save her life.
LaMontagne left her appointment with prescription medications, pamphlets for nearby recovery resources and a plan to get treatment for a substance abuse disorder. She’s been sober ever since.
“I never got to have my last drink,” she says.
Stories like LaMontagne’s might explain why your primary care doctor has started peppering you with questions about health issues you’ve never brought up yourself. If you’ve fielded inquiries about your relationship with alcohol, drugs or any other taboo substances, don’t be offended or alarmed: A new recommendation from the U.S. Preventive Service Task Force aims to make experiences like this more common. The group, a volunteer panel of experts that reviews research and makes recommendations for best practices, released a draft recommendation in August calling for universal screening for illicit drug use among American adults. This builds on a 2018 recommendation to screen all adults for “unhealthy alcohol use.”
Substance use disorder — what we’re used to calling addiction — is a leading cause of injury, death and disability. It’s also a disease for which we have effective treatment methods. For these reasons, USPSTF co-vice chair Karina Davidson says universal screenings could be a relatively straightforward way to spot problematic substance use early and save lives. And yet, not everyone’s sold on the idea of making this screening a standard part of primary care visits. Among other concerns, some experts question the value of screening every single patient for a problem unless treatment for it is widely accessible.
Why and how doctors screen
Preventive screenings are an essential part of primary care. Doctors ask an array of questions to zero in on health issues for which patients might be at risk. The specific questions they ask often evolve to reflect current public health concerns and dominant cultural flash points. Domestic violence screenings, for example, became standard following increased acknowledgement of domestic abuse as a common social problem with far-reaching health effects. Now, with overdose rates at an all-time high, efforts to curb addiction have gained urgency.
“The opioid crisis has really helped concentrate attention and resources on trying to detect this as soon as it is humanly possible to detect,” says Cathy Morrow, chair of community and family medicine at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire.
Screening won’t solve the addiction crisis, she says. But it could get more people the help they need by opening the door to a conversation and, ideally, making patients feel comfortable enough with doctors to be honest about their substance use.
Addiction screening is designed to be universal for a reason: asking every patient the same set of initial questions prevents doctors from making biased decisions about which patients to screen, Morrow explains. Without universality, a doctor might assume they know which patients are most likely to have substance issues, drawing at least in part on stereotypes. If screening were discretionary, LaMontagne might be the sort of outwardly high-functioning patient a doctor wouldn’t bother screening.
“As soon as you think you know who’s at risk for what, you’ll prove yourself wrong,” says Morrow. “Every one of us has had a patient who died before we knew they had a true substance use disorder problem. I can’t tell you how disturbing that is for any provider.”
The universal approach also tends to sit better with patients, who are less likely to take offense to questions about which drugs they’ve dabbled in, or whether they drink alone, if they know doctors aren’t singling them out.
An imperfect tool
While addiction screening is the best early-detection tool doctors have at the moment, it’s still imperfect. Screening only works if patients are honest. It also taxes doctors’ already limited time.
“If you’re asking them about cancer, you might not be asking them about alcohol; if you’re asking about alcohol, you might not be asking about cancer,” says Keith Heinzerling, an addiction medicine specialist in Santa Monica, California.
There’s also the question of whether it makes sense to incorporate substance use screenings into primary care. This strategy targets people who proactively go to the doctor for routine matters. As Heinzerling points out, that’s typically not who most needs addiction treatment. But generalizations don’t always bear out. There are people like LaMontagne, who struggle with substance use but remain actively engaged in their care. Universal screening could make a big difference in their lives.
Another potential flaw (perhaps the most glaring) in universal substance-abuse screening is the fact that access to treatment is far from universal. In theory, primary care providers could be the first line of defense against addiction; they’d identify people with worrisome habits and connect them with resources to set them on a better course. But this only works if everyone who needs those resources can realistically get them.
“If I screen and the patient comes back positive, I need an army behind me to support that process.”
While addiction is common in the U.S., treatment for it isn’t. A 2016 Surgeon General’s report found that about 8 percent of Americans meet the criteria for substance use disorder, and only 10 percent of that group receives treatment. Often, that’s because people don’t know where to turn for help or are too embarrassed or ashamed to admit they need some.
“If I screen and the patient comes back positive, I need an army behind me to support that process,” says Gerard Hevern, a family physician in Suncook, New Hampshire. That army might include social workers, treatment facilities, prescription medications to curb cravings, and other resources that are either unavailable or unaffordable to many Americans.
Although it might seem unfair to screen patients who lack access to treatment, many people who screen positive for substance use disorder during primary care visits have an early-stage, less severe form of the disease. For them, widely available peer support programs like 12-step meetings or simple behavioral changes could be enough, Heinzerling says.
According to Davidson, the USPSTF recognizes that access to recovery resources is an issue. She says doctors need to have systems in place and do research on available resources before they start screening patients: “They need to already have those referrals, that phone number, that resource pamphlet in hand.”
Hevern screens most of his patients for substance use disorders. He starts by asking about their family history with substances, then about their cigarette use (which is often linked to substance use disorders). Then he asks open-ended questions about drinking and drug use. In addition, Hevern has undergone the special training that physicians need in order to prescribe suboxone, a medication used to treat opioid use disorder. As a result, he feels better equipped to serve patients who screen positive.
Even without training, doctors can do simple things to improve care for patients dealing with substance abuse. For starters, they can make an effort to treat those patients like everyone else they see.
“Doctors have to remind themselves that drug or alcohol problems aren’t much different from other problems,” Heinzerling says. As with any potentially embarrassing medical condition, respect and open conversation can go a long way. It’s about reacting well to that first disclosure and creating a safe environment — [trying] to normalize it.”
Sometimes, though, finding a provider who normalizes addiction falls to the patient. After LaMontagne’s nurse practitioner moved to another practice, she began seeing a doctor who, she felt, shamed her for her past drinking behavior. So she found someone else. Putting in the work to find a provider who understands her illness, she says, is part of her commitment to her health. After a decade of sobriety, she still credits strong relationships with primary care doctors for helping her stay on track with her recovery.