Cross-analyzing addiction specialist and patient opinions and experiences about addictive disorder screening in primary care to identify interaction-related obstacles: a qualitative study

This qualitative study recruited addiction specialists and patients with addictive disorders with purposive maximum variation sampling between April 2017 and November 2019. Data was collected, verbatims were coded independently according to the data triangulation principle, and ongoing inductive analysis and constant comparison was performed using a grounded theory approach [26].

In this study, addiction specialists were defined as physicians with extensive training and education in addiction treatment. Addiction specialists were recruited from primary care practices, hospitals and academic departments in the Centre-Val-de-Loire region, France. The first addiction specialist was contacted by phone then others were recruited using a snowball technique. Nine specialists aged between 38 and 62, of which seven were male and two females were involved. They worked in a hospital or outpatient setting or primary care and had varied specialties including addiction, psychiatry, emergency and general medicine and academia (Table 1). Eight patients with a DSM-5 confirmed addictive disorder were recruited from primary care, addiction specialists and hospital emergency units. Patients with tobacco addiction were excluded. There were three males and five females aged between 18 and 65. The living area was urban for five and rural or semirural for three. The treatment stage ranged from active to long-term abstinence. Four were employed, two unemployed, one student and one retired. Addictions included alcohol, cannabis, heroine, ecstasy, codeine, benzodiazepine, and gambling (Table 2).

All participants were informed about the study and its objectives and provided informed consent (Additional files 1 and 2).

Interviews with addiction specialists were conducted in their workplace. Interviews, guided with a specifically designed guide to explore addiction specialist experiences and opinions about addiction screening in primary care lasted between 31 and 79 min. The guide was modified throughout the data collection process to include new concepts that emerged during the simultaneous analysis (Additional file 3).

Interviews with patients with addictive disorders were conducted in their usual care setting Interviews were guided with the McGill Illness Narrative Interview (MINI) guide [27, 28] (Additional file 4) and lasted between 53 and 99 min. This guide explores life trajectories through narrative, prototypical and causal biographical reasoning.

Two male general practitioners (GP) who had received interview training, conducted all interviews. The participants did not know the interviewers before the study and no-one else was present during the interviews. The interviewers informed each participant about their role as a GP and that this research was for their theses.

All interviews were audio recorded and transcribed. All verbatim was coded to anonymize participant identity using P1-8 for the patients and AS1-9 for addiction specialists. No interviews were repeated, and no notes were made during the interviews. Transcriptions were not shared with participants.

The verbatim from each interview was coded according to the data triangulation procedure as follow: firstly, two analysts performed the initial coding using a coding book where necessary and discrepancies were resolved by discussion with arbitration from a third analyst if needed, until data sufficiency. Secondly, categories were built from the initial coding book using the same triangulation procedure. Grounded theory was used for the specialist codes and a narrative approach was used for the patients with addictions. Thirdly, all the initial verbatim was reanalyzed and categories were compared and redefined according to the grounded theory approach. Convergences and divergences were identified and analyzed to create an explanatory model. The software package QSR NVivo11® facilitated category analysis and systematic comparison.

To ensure the results were relevant, two addiction specialists, a narrative research specialist and four GPs provided their opinions about this analysis. All participants were invited to provide feedback on the verbatim from their interviews and study findings.

The Espace de réflexion éthique région Centre approved this study (N°2017–059, le 09/01/18) (Appendix 3). This study is registered with the Commission nationale de l’informatique et des libertés (CNIL) under N°2017–093 (Appendix 4). The research was reported in accordance with the COREQ/SRQR guidelines.

Some patients felt their physician lacked consideration: “He knew it, he wasn’t stupid, he must have realized that I wasn’t in great shape! But he never asked me about anything, I think he didn’t really care!” [P1]. Others described feeling left alone to deal with their condition: “I told them about it, but nothing happened” [P6]. Some thought that they didn’t need to say it: “People’s discomfort can be seen, even when they try to hide it” [P8] and seemed disappointed when the physician’s reaction was not what they had expected: “I told him that I have a problem with alcohol. He said: ‘It’s not that serious. Just take the Esperal®’. It was not what I needed, I needed much, much more! Things didn’t turn out well after that” [P5].

Some addiction specialists also shared this impression that some physicians lack investment: “Patients feel that their physician didn’t want to take care of them. Saying ‘You’ll come back when you’re ready’ is just terrible” [AS8]. Most specialists highlighted the importance of taking the patient’s reluctance to talk into consideration: “When patients manage to talk about it, there are physicians who say, ‘well now you have to stop drinking, we’re going to do a withdrawal, I’ll write you a prescription’. If the patient seems reluctant or starts to be a little scared by all this, the physician stops and says ‘Well, come back when you’re ready!’ He’ll be back 20 years later as an emergency with decompensated cirrhosis” [AS8]. Many addiction specialists also regretted the fact that physicians sometimes miss the opportunity to start treatment, which can mean the patient finds it harder to change.

This study reveals shame, low self-esteem and a sense of worthlessness in patient discourse which has been described in previous studies [29‐31]. The double stigmatization resulting from the caregivers’ views and the patients’ negative view of themselves, explains why patients are reluctant to disclose their problem. “Most patients won’t bring it up themselves” [25].

Physicians are also reluctant to raise the subject of addictions [31, 32]. Addiction specialists suggest that some physicians avoid the subject since they believe the drive for change comes from the patient [33].

For the first time, cross-analysis of patient and addiction specialist verbatim revealed the new concept of shared self-censorship with mutual avoidance. Avoidance has long been described in anxiety disorders and is a factor in maintaining anxiety. In order to control their anxiety level, people with anxiety disorders often avoid situations associated with stress and learned helplessness responses [34]. In this current study, the anxiety-provoking situation is starting a conversation about addictive disorders [35].

Since addictive disorders are associated with an accumulation of co-morbidities, the need for physician involvement increases [36]. However, our study reveals that these accumulated addiction-related co-morbidities do not lead patients to start talking about their addiction. Existing literature discusses “teachable moments”, such as an overdose, which can be used to combine acute treatment with referral to an addiction specialist [25, 31]. This implies that this turning point is a passive moment, something that the physician can utilize to begin specialist addiction therapy.

In contrast, our study reveals that each patient has their own personal red line. This turning point is patient-specific and is triggered by an event in the patient’s life leading to an active decision to change and start talking. Relatives and physicians cannot trigger a person to cross their personal red line but patient verbatim suggests that they want their physician to gently encourage them to change. To our knowledge, this is the first study to reveal that this turning point is truly personal and different for everyone.

Our results suggest that when physicians avoid asking about problematic substance use, this can lead the patient to trivialize the problem, “if you don’t talk about it, there is no problem” [AS7]. This echoes the “not sick enough” concept known in other behavioral disorders [37]. Furthermore, the patient’s resistance to discuss their addiction until they cross their own red line can frustrate physicians [38, 39]: “when you ask the question but don’t get an answer, it’s easy to get impatient. If after asking several times you still have no response, you stop asking” [AS6]. When the patient finally starts to talk, they are sometimes disappointed by their physician’s response, feeling that they “don’t care” [P1] which reinforces the disorder and can lead to initiation of care inertia. Care inertia results from the interaction of different factors, mainly physician-related factors such as reactive rather than proactive care, and patient-related factors including poor communication and low health literacy [40].

Addiction specialists highlighted the importance of a standardized medical approach to prevent preconceptions in primary care [41] often through the use of questionnaires as per current health recommendations [42‐44]. Some formulations have been suggested [45], without providing advice on how to start the discussion. This can create an obstacle to early screening.

Patients described social exclusion and belonging to a stigmatized social group [31] labelled as addicts. Removing this label requires a change of social circle but, “it’s hard to get a new social life afterwards” [P4]. The physician can become the first social contact in this process making consultations a transitional tool for dynamic change. A patient-centered approach is essential to ensure physicians can adapt to each patient’s level of understanding, and their motivation to disclose and change.

Patient-centered care is widely recommended as it prioritizes the unique needs of each patient and encourages a more equal balance of power between physicians and patients. In substance use disorder treatment, therapeutic alliance including empathy and non-judgment is the most important principle of patient-centered care, followed by shared decision-making, and individualized, holistic care [46].

Recent thematic analysis studies brought additional understanding of substance use screening through analysis of patient and physician opinions [25, 47]. These studies discussed the importance of regular annual screening within a limited amount of time, the benefit of using self-reported questionnaires to limit discomfort in face-to-face consultations, and physician knowledge deficit. Our study, which adopted a theoretical analysis approach based on grounded theory, enables a more in-depth exploration of these themes raised using a thematic approach.

Furthermore, for the first time, cross-analysis of addiction specialist and patient opinions has highlighted the gap between what addiction specialists believe they should be doing to meet patient expectations and what patients really expect from their caregivers. Patients described wanting an empathetic, non-judgmental, and caring physician to help them break their self-censorship. They would like the physician to make the first move, ask them when they are ready to start talking, and listen to them when they are ready to talk. However, they fear that their physician will stigmatize them and hinder their motivation to talk. This demonstrates the importance of physicians remembering patient expectations during consultations. In contrast, physicians tend to use a psychometric, technical identification approach using tests to identify disorder severity. This difference in expectations can create an obstacle to early screening.

The new patient-specific red line concept should also be considered when trying to identify addictive disorders. Each patient has their own red line and may need encouragement to talk, but they do not expect physicians to be so passive as to say, “You drink, come back when you are ready to stop” [AS8]. In addition, patients in our study described the importance of human contact and having an understanding physician. Interestingly, they also emphasized that the physician’s experience with substance use disorder was not important which opposes findings in existing literature stating that a lack of knowledge could be a potential obstacle [47]. Approaching the issue with an empathetic, patient-centered approach which is not overly standardized may facilitate discussion. Furthermore, providing a friendly, trusting, relaxed and safe environment may encourage patients to cross their red line.

The reluctance to start talking has been discussed at length in the literature but our results provide more detail on this concept. Not only do patients have a certain reluctance to talk which reinforces the caregiver’s frustration, but caregivers trivialize the addictive disorder which reinforces the trivialization of the disorder that the patient already perceives. Frustration and stigmatization are known to negatively impact physician–patient relationships [33, 38, 39, 41]. Similarly, it is possible that trivialization may impact the therapeutic bond. These reflections, illustrated by our results, reveal the association between omission and trivialization, confession and stigmatization, concealment and frustration, and inattention and deception, which help to clarify the patient-physician relationship surrounding addictive disorders.

New technologies and e-health are starting to facilitate the early screening process making the physician’s job easier. A tool to help identify tobacco and alcohol use disorders has already been developed using Artificial Intelligence [48] and an e-SBIRT version has been developed [49]. However, whether these innovations make it any easier for the patient remains to be seen.

This study has several main strengths. Grounded theory analysis enabled concepts to be identified from cross-analyzing specialist and patient experiences [26, 50]. Furthermore, the strictly inductive analysis and the data triangulation limited any influence from investigator subjectivity. The COREQ criteria were respected throughout the study [51].

The purposive sampling provided the required diversity in the patient population. However, there are very few addiction specialists so obtaining maximum variation in this population was difficult. The nine included addiction specialists do however represent around 80% of addiction specialists in the Centre-Val-de-Loire region, France making our sample an adequate representation.

This type of analysis is subject to the typical limitations including interpretation and confirmation bias [52]. However, multidisciplinary collaboration (psychiatrists, addiction specialists, GPs, sociologists) should have enriched data analysis and limited this bias. Member-checking can also reduce confirmation bias. Unfortunately, despite being given the opportunity to do so, none of the participants provided feedback on the verbatim from their interview or study results.

Patients with tobacco addiction were not included in this study as there is less stigma surrounding this addictive disorder, screening often occurs through cardiovascular prevention and monitoring, there are no psychoactive consequences and there is a lower level of social, legal, or violent consequences associated with this substance.

The concepts revealed in this study and elements in the literature have been used to create a theoretical model of addictive disorder screening practice (Fig. 1). To continue the analysis of addictive disorder screening dynamics started in this study and illustrated in the theoretical model, further studies are required to examine the perspectives of those involved in primary care including GPs, patients only monitored in primary care, and paramedical professionals. For example, it has been shown that different healthcare professionals have different strengths and weaknesses when it comes to SBIRT training and implementation [53]. Until the theoretical model has been completed with this information it is difficult to suggest solutions to the barriers revealed in this study. However, completing the theoretical model will provide some ideas to help patients and caregivers open the door to a conversation that is difficult to start and help implement a collaborative team-based care approach.