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Awkward however Necessary Affected person Conversations: Problematic Drug and Alcohol Use – Rheumatology Community

This column contains a number of reviews with practical suggestions to address the many tricky needs of your patient population. This series began with an introduction to the sexual health issues of patients – along with a healthy dose of self-reflection required ("Bring them Fishing: Respecting Patient's Sexual Health Needs and Exercise Culture"). The series continues with this immersion in problematic substance use and other important but sensitive issues such as personality disorders, home patient safety (violence, abuse or self-harm) and cognitive impairment to continued medical decision-making and the de-escalation of agitated, angry patients. There are more dozens of difficult conversations, so please get in touch with suggestions.


Talks about alcohol and drug use are complicated but overdue. Only last month, data from the National Drug Use and Health Survey (NSDUH) of 2018 was published. The NSDUH report was extrapolated from a survey of around 67,500 people from all 50 states and from DC. The data for 2018 reflects some positive trends, including a decrease in new substance misuse of heroin and analgesics (Substance Abuse and Mental Health Services Administration, 2019). However, there was also a significant increase in daily marijuana use in young adults (18-25 years), especially in young pregnant women. The same young people said that their marijuana use is linked to opioid abuse, heavy drinking and depression. These risks are evident in the 2018 data, which shows an increasing rate of severe mental illness, major depression, and suicidal events in this age group (Substance Abuse and Mental Health Services Administration, 2019).

In total, 164.8 million people over the age of 12 (60.2%) said they had consumed substances last month (ie tobacco, alcohol or illicit drugs, Administration for Drug Abuse and Mental Health, 2019). Approximately 139.8 million Americans (aged 12 and over) drank alcohol in the previous month, and 67.1 million of those respondents said they had alcohol excesses. More than 2 million adolescents (1 in 11 people aged 12 to 17) said they were drinking alcohol last month and half reported alcohol excesses. In total there were 4.9 million alcohol consumers in 2018 (Substance Abuse and Mental Health Services Administration, 2019).

Regarding illicit drugs, about 20% of people (12 years and over) said they had used illicit drugs last year (an increase over previous years), with marijuana users at the top of the list. 16% of respondents said they had used marijuana the previous year (Substance Abuse and Mental Health Services Administration, 2019). In addition, there were more than 3.1 million new marijuana users last year. Abuse of prescription painkillers has been steady over the past year, 3.6% of the population (12 years and over) reported abuse last year, most (63.6%) reported pain complaints. Last year, there were 1.9 million new users of prescription painkillers. This is less than in previous years (Substance Abuse and Mental Health Services Administration, 2019).

At the other end of the substance use continuum, 20.3 million people (12 years and over) met the criteria for substance or opiate use disorder (SUD / OUD) last year (Substance Abuse and Mental Health Services Administration, 2019). This includes 14.8 million people with alcohol abuse disorder, 8.1 million people with illicit drug use disorder, 4.4 million people with marijuana use disorder and 2.0 million people with opioid-related drug use, a decrease of 2.1 million in 2017 equivalent. In particular, of the 2 million people with OUD, only 400,000 were heroin users and the remaining 1.7 million people were abusers of prescription painkillers. In total, more than 21 million people reported the need for substance treatment last year. These include 1 in 26 adolescents, 1 in 7 young adults and 1 in 14 adults (aged 26 and over, Drug Abuse and Mental Health Administration, 2019).

Increasing consumption of drugs and alcohol reflects accessibility, growing psychosocial vulnerability, and changing social norms; However, the few significant losses, including the slight reduction in opiate use, are due to better drug and alcohol screening and short interventions in the medical environment.

Next page: Identification of Problematic Substance Use.

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