Tough Talk: Initiating patient conversations about substance use disorder

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As healthcare practitioners, we encounter substance use disorders (SUD) in the clinical setting on a daily basis – even though we may sometimes be unaware or even unable to adequately address the topic with our patients.

We sometimes skirt the topic by asking the patient to “check a box” on a medical history form that describes his or her drinking pattern or use of illicit drugs. This is not a substitute for an adequate screening and conversation for the simple reason it has very little benefit. There are a variety of reasons that patients may fail to accurately self-report – fear of disclosure, embarrassment, fear of change, and fear of judgment.

Patients often fail to volunteer an accurate picture of sensitive topics, whether it’s a history of childhood abuse, intimate partner violence, or substance misuse. Patients may view these admissions as potentially damaging to their physician-patient relationship or even, potentially, to their career or reputation. In my experience, patients may be concerned that there is no approach to their problem that won’t result in disruption of relationships, career, or finances. Although we recognize substance use disorder as a medical condition, these disorders are, like many mental health disorders, associated with a stigma that can prevent patients from seeking help until their related health conditions – or fractured relationships or financial issues – have reached the point where intervention is too little, too late.

Lack of disclosure from the patient can have many negative consequences, ranging from a missed opportunity to reverse the course of alcohol-related liver disease to incurring significant risks associated with undisclosed drug use that can derail an otherwise routine surgical procedure.

Because we know this is an issue, as healthcare providers, we need to be more proactive about initiating the conversation around substance abuse. The fact is, we have a number of effective tools available to mitigate withdrawal, to reduce cravings, and to treat underlying conditions. In essence, we can offer hope.

The initial decision to use a substance may be a matter of judgment, but much as COPD begins with a poor choice, patients with SUD have experienced pathophysiologic changes akin to alveolar wall destruction or insulin resistance that results from poor dietary choices. These changes do not represent a moral failure and we in the medical community should seek any opportunity to intervene as early as possible.

So why don’t we do a better job of screening?

Many healthcare practitioners feel unprepared and have not had adequate training for encounters with a population with a lifetime prevalence of drug use disorders of 9.9%.1 A good place to begin to better enable healthcare providers to intervene is widespread dissemination of evidence-based methods for screening and counseling that can be successfully deployed in a primary care setting or an emergency department. Given the scope of the problem, we should increase our familiarity with tools for screening and intervention that are already widely available – the CAGE questionnaire, the SBIRT, among others

But that’s not nearly enough. When we identify a healthcare problem in any setting, we generally have a mental algorithm that allows us to present the patient with effective treatment options. There is still confusion in the medical community about where the evidence stands on treatment of substance use disorders. Providers need to be familiar with the complete array of evidence-based treatment options when opening up a discussion about SUD with a patient. We are able to present the “gold standard” and alternative treatments for most disorders we encounter, usually before an initial consultation with a specialist. When it comes to substance use disorder, a common cause of significant morbidity and mortality in our country, we often fall short.  This may compound our unwillingness to raise the topic. Most of us have had training in opioid prescribing, but the horse is already out of the barn in many cases. It is often too late for primary prevention. We need to improve our understanding of treatment options, as SUD is not a “one size fits all” disease.

Substance use disorder continues to affect millions of Americans and their families – screening is as important to health promotion and maintenance as screening for breast cancer or colon cancer. Adequate knowledge of the broad outlines of the problem and the range of potential solutions, coupled with compassion and an active effort to acknowledge and rise above personal bias and accumulated misinformation will make the conversation easier to initiate effectively.

  1. Grant BF, Saha TD, Ruan WJ, et al. Epidemiology of DSM-5 Drug Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III. JAMA Psychiatry. 2016;73(1):39–47. doi:10.1001/jamapsychiatry.2015.2132
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