Take as an example, an injured worker who is prescribed hydrocodone twice daily. He does not seem to be abusing it; but he is dependent upon it. But lately he has been surly, nasty, hostile and verbally abusive when I talk to him.
The abuse may not be of the hydrocodone per se but of the combination of hydrocodone and alcohol. Alcohol can potentiate not only the effects of hydrocodone but also its mood-related side effects such as irritability.
Staying home all day, inactive, mobile only when physical therapy or monthly doctor visits are required_it is easy to fall into the habit of drinking beer and watching television. This feeds upon itself.
The first order of business would be to differentiate between what is pain_what is depression_and what is alcohol abuse for this type of patient. Although direct questioning is usually met with denial, here are ways of obtaining the data regarding what factors are causing the mood changes.
Combine this with a deteriorating financial picture and appreciable tension in the household. Note that some of these patients are at home either with the children or when the children come home from school. They feel burdened by this added responsibility but more importantly that their adult role is impugned by being a non-working adult.
Then there is the question of _why are they abusing any substance?_ Most often this is a futile attempt on the part of the patient to deal with the feelings of helplessness and mounting fear of the future.
Do they need to _talk about this?_ Sometimes. Will adding an antidepressant to this picture be helpful. Usually not. Alcohol and antidepressants can result in severe consequences.
It is like all of these situations, first you need to find out _why_ and then determine _how._