The Clinical Assessment of Substance Use Disorders – role-modeling the initial visit

good morning mrs. Anderson it's so nice to see you again hi dr. Sheeler tell me what brings you here today well my back has been acting up I had to miss a couple days of work I called your office and they said I had to come in to see you before I could get a note well I'm glad you were able to come in today I really haven't seen you since the accident which I guess was about six months ago yes mm-hmm how have things been going for you since then well I I've been seeing the orthopedist and physical therapy every six to seven weeks and physical therapy in between there and has that helped I'm not I don't think it's helped doctor to be honest I still have as much pain now as I did back then and so what do you do to help the pain how do you make yourself more comfortable the only thing that really helps is the medication okay and what kind of medication are you taking percocet purpose it okay and can you tell me how often you're taking the percocet well when it acts up maybe maybe two or three times a day and is that every day or do you take it a couple days in a row until that until it feels better and when the pain gets better then how long can you go without taking the percocet sometimes a couple days maybe three or four and you said you take it a couple of times a day when you need to take it could you tell me a little bit more about when you take it during the day well you know so I can make it to school in the morning maybe depending on how bad it is in the afternoon and and then you know so I can sleep at night okay so you do use it to help you sleep can you tell me a little bit about the trouble that you've had sleeping I wake I'll wake up with in a lot of pain it wakes me out okay and what do you do when you wake up with the pain well if I have the medication I'll take it then but if not I have to write it out so you don't sounds like you don't always have the medication available know who's been prescribing the medication for you my husband he's a doctor as a cardiologist right he is he is yeah and anybody else has been prescribing the pain medicine for you um once in a while the orthopedist does okay but it sounds like there are times when you're running out right and my doctor and my husband said I should probably come to you so you described the pain and and what's happened since the accident anything else going on in your life now well I have a new classroom this year yeah they transferred me from my school that I loved I was an elementary teacher now I'm in a high school hmm and how was that going it's pretty not well what's what's happening in the classroom that's that's upsetting for you or difficult well they're high schoolers they're like men and there's like four or five that I have real behavior problems and I have no help no teachers aid this year Wow so it's it's very out of control and you've been missing a number of days of work yes it's because of the pain or is it because work has been difficult or do you think of it I can't give a nation well you know I can't get in there because of my back pain so it's mostly the back pains is keeping you away from your job anything else that you've noticed that's that's changed for you in the last six months since this accident well the only other thing is my 15 year old I noticed him he had some same behaviors as these these high-schoolers that I have he worries me he's hanging around with a crowd that I really don't want to do and I think I think he might be smoking marijuana what makes you think that well you know he comes in jolly one minute and and very tired than necks and eats non-stop and and you know they're all like about 16 I'm afraid of them driving and having an Asscher sure that's that is a worry and you have two other children right yes and how are they doing they're doing pretty well they're they're in college both in college now okay so that's going on mm-hmm so we talked a little bit about your back pain and about the trouble that you've had sleeping are you having any other symptoms that you're concerned about how's your mood been gosh I well my mood I'm Vera I just feel very down lately how would you describe that I just I'm not very positive I used to be like enthusiastic and but I don't feel that way lately really and are you able to enjoy things that you usually enjoyed no no how's your concentration I guess it's pretty poor it's it's hard for me to stay focused even at school and teaching and you know I blame it on the kids but I think it's media as well are you feeling nervous or anxious I do feel nervous alone yeah and how would you say you're feeling about yourself as a person not not real good I mean I don't feel like I'm doing the best that I can okay I can do do you have times where you feel when you're feeling down that you feel like life's not worth living have you had thoughts about hurting yourself no no we're hurting anybody else no no no so it sounds like you could be depressed as well as you know struggling with this back pain and struggling with your work situation have you ever had problems with depression in the past well I didn't call it depression but I did feel very down after after two of my births to two of my children so in that postpartum period and what was that like for you with what happened it was really tough I I couldn't even get out of bed some Oreos yeah what kinds of symptoms did you have besides not being able to get out of bed well very tired no energy just felt really bad about myself and my mom had to come did she like I couldn't have done it without her depression tends to run in families and I wondered if anybody in your family might have had problems with depression as well my mom did yeah yeah she had a couple periods of be feeling really down then like like I had and do you know what kind of treatment she might have gotten no she ever talked about it not really so she kind of kept me just waited it out yeah so we've talked a little bit about your family history of depression your mom's history of depression anybody else in the family that you know grandparents aunts uncles cousins brothers or sisters that might have had problems with depression not that I know of and because problems with addiction tend to run in families as well and run in families that have problems with mood and depression tell me a little bit about your family history in terms of addiction anybody that's had a problem with dependence on alcohol or drugs well my father drank a lot did he and is your dad still alive you know now what did he die from cirrhosis cirrhosis okay and when he was ill did the doctors talk at all about whether that was related to his drinking alcohol yes did the family at the time think he had a problem with alcohol yes and what made you think that well he was mean he had a middle streak and abusive and yeah and that only happened after he drank a lot so when he was drinking him he would get mean and abusive all right well let's come back and talk a little bit about why he came in today to see me you mentioned the back pain and in a doctor's note can you tell me a little bit more about what you'd like me to be able to do to help you well I need the doctor's note to get back to school I did have to take off the couple days and and then if I could have the percocet to take away the pain so I can get back to work well let's talk a little bit about the percocet and it sounds like you've been taking it you know sometimes a couple of days in a row sometimes from what you've said you've taken a couple of days off from using it have you found that you're needing to use more of it than you had in the past I don't think so and have you felt it all like you need to cut down on your use well I think I'm at the minimum as it is and it's still the back pain doesn't go away so if I cut back it's just going to be worse and has anybody that you're close to in the family been talking to you about you're used to percocet and expressed concern about it well only my husband and I he's just so busy and he would rather me see you then then him just writing the prescription okay and that's what he's been doing up until now and have you felt guilty at all about using it guilty no do you find sometimes that you wake up in the morning and you're feeling kind of shaky and you need to to take the percocet to settle yourself down well I do I do find myself nervous I don't know if shaky it is that is what it is but I don't use that to calm myself down I do use it for the back pain what do you use to calm yourself down because it sounds like you know between the sleep problem and the nervousness and the depression that you must be feeling pretty awful at times well once in a while I'll go and have some drinks with with friends after work and then I do smoke marijuana in the evening so that I can sleep and calm down it does relax me and is that something that you do every night pretty much yeah and how about other times during the day not usually no and you said you drink with your friends occasionally yeah how often would you say that is not more than a couple times a week and do you do that at home and a restaurant and a bar usually well you usually at a restaurant that has a bar uh-huh and so how many drinks would you say that you have just a couple maybe two or three well it sounds like you're struggling with a lot of things right now certainly the stress at work the back pain that's you know been a result of your accident which you know at this point should be getting better it's in almost six months and I know you've been working hard at doing your physical therapy to try to help that and it also sounds on top of that like you have some worries about your son so there there are a number of things going on right now that I think are playing a role here and it sounds like you may be depressed one of the things that we know is that women who have problems with depression some sometimes in fact more than sometimes will turn to drugs or alcohol to help medicate their depression and I wonder if that may be something that could be going on with you right now and it may be why you know you needed to use the purpose it and continue to need the percocet despite the fact that your back should be healing at this point well I don't think so a doctor it really does hurt my back is you know in a lot of pain and I don't think that I'm questioning at all the fact that you we are having pain I think you really are having pain and that you know and is feeling very painful but we do know that pain painful symptoms or symptoms of pain can be very common in people who have depression as well so one of the things that I think we need to try to sort out together is how much of what is happening with you right now may be related to the depression which you know we can treat you for or whether in fact as as a secondary problem you've now developed some dependence on the pain medication that you've been taking I don't I can stop it I mean I wouldn't say that I was dependent on it but what would I do about my back pain okay well I think that's something that we need to to talk about and continue to work on one of the things that we found though is that if you start to treat the depression that very often the back pain starts to get better but we also have to find out how dependent you may be on the pain Medicaid and taper you off of it if that's in fact the case what I'd like to do mrs. Anderson is write out a prescription for an antidepressant for you today and we'll talk a little bit about how you take it in what some of the side effects potentially could be and also write out a prescription and a schedule for taking you slowly off your percocet okay okay


  1. This is a premature diagnosis of a major depressive disorder. She should be assessed by a pain specialist and determined in there's any alternative treatment that has less burden for drug dependence or an intervention such as nerve blocks to target her pain before assigning a clinical depression diagnosis.
    I agree that chronic pain can worsen depression, but removing any pain medication will not improve her quality of life and will definitely magnify any depression symptoms. Also, many other features of major depression including their adverse effects on her life and functioning weren't assessed, in order to arrive at that diagnosis.
    The patient didn't seem too convinced as well that she was truly depressed and her opinion wasn't openly explored by the physician either. If that was my doctor, I'd be looking for another one.

  2. I do not know what is worse though – Percoset or anti-depressants, most of which carry Black-Box warning.  Good video on conducting interview though!  Thank you.

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