Ideally, outpatients who currently abuse drugs should be enrolled in a drug rehabilitation program; however, patients with advanced medical illnesses may not be able to be enrolled. The health care provider may outline for the patient the role of the treatment team, what is expected of the patient, and the consequences to the patient should he or she continue to abuse drugs while receiving treatment for medical illness. Patients must receive detailed instructions for taking prescribed drugs responsibly. They must be seen frequently so symptom control may be maintained and drug abuse may be monitored. Frequent visits also avoid the need to prescribe large amounts of drug at one time, and may help the patient stay on the treatment schedule and attend appointments with the physician. Some patients may find that a "twelve-step" program is helpful in stopping illegal drug use while they are receiving treatment.
Outpatients may be required to undergo periodic drug testing. The patient should be informed in advance of the consequences of a positive test. A urine test that indicates the patient is using illegal drugs may result in the need to visit the outpatient department more frequently, smaller quantities of prescribed drugs, referral to a drug rehabilitation program, or other restrictions.
If the patient lives with family members who are substance abusers, the family members can be encouraged to enroll in a drug treatment program to help the patient avoid illegal drugs and alcohol. The patient should also be aware that friends and family members may attempt to buy or steal the prescribed drugs. It is very helpful to identify people who will be supportive of the patient.
A treatment team that includes a specialist in addiction medicine may be able to provide more effective treatment for the outpatient with a progressive medical disease and a history of substance abuse than can a single physician.
Patients who have successfully stopped abusing drugs or alcohol may be reluctant to begin using prescribed drugs for their medical illness for fear of developing an addiction. They may fear rejection from friends and family members who will object to their use of prescribed drugs, and they may fear that others will attempt to buy or steal the drugs. The health care provider should help the patient resolve these concerns and assure the patient that use of opioids to control symptoms of progressive disease does not result in the euphoria experienced by opioid abusers who do not have a medical illness.
If the patient is very reluctant to begin opioid therapy, the physician may develop strict guidelines for use of the prescribed drug to provide the patient with a sense of control. The patient may also be provided with counseling to help identify situations in which he or she is likely to abuse drugs or alcohol, and to develop strategies for avoiding future abuse of illegal or prescribed drugs.