Managing Substance Use

It can be daunting to ask your patients about using substances. Here are some strategies for navigating the conversation:

•  Ask permission to ask sensitive information: 
  • Examples: 
    • Would it be alright if I asked you some questions about your substance use? 
• ​​​​​​​Validate feelings and normalize the conversation
  • Examples:
    • It’s common to feel uncomfortable, embarrassed, or even shame when talking about using substances, but remember that addiction is a medical disease, not a moral decision.
• Ask specific questions
  • Examples:
    • Can you tell me how you use opioids/marijuana/cocaine/methamphetamines/alcohol?
    • Do you use pills, powder, or other form?
    • Do you smoke it, use a needle, snort it?
    • How much do you use?
• Frame questions neutrally in a way that doesn’t assume non-use
  • ​​​​​​​Example: 
    • ​​​​​​​​​​​​​​How often do you use street drugs? Daily? Weekly? Monthly?
• Express gratitude and listen when they share their stories
  • ​​​​​​​Examples: 
    • ​​​​​​​Thank you for sharing this with me.
    • I appreciate you trusting me with this information
• Let patients know that your questions are standard
  • ​​​​​​​Example: 
    • ​​​​​​​​​​​​​​I ask all of my patients very specific questions about their use in order to better understand how we can improve their health and keep them safe. 
• Reassure patients that care is not contingent on their responses, your intent is to provide them with help, if desired 
  • ​​​​​​​Example: 
    • ​​​​​​​Recovery looks different for everyone. There are many ways to improve your health and stay safe, including medications and treatment plans, if that is something you are interested in.
• Address confidentiality concerns
  • ​​​​​​​Example: 
    • ​​​​​​​My goal is to respect your privacy while abiding by the protections provided by law for patients. 
• Provide hope:
  • Example:
    • I am excited to support you on this journey of healing.  Treatment works and often helps people to lead more meaningful and fulfilling lives.
    • It doesn’t always have to feel this way, things can and do get better.
    • You have a lot to look forward to on this journey to better health.

To learn more strategies for navigating conversations with patients about their substance use, review this module on empathy from the Centers for Disease Control CDC: “Empathy: Talking to Patients About Substance Use Disorder.”

(Sources: CDC and PCSS)

Stigmatizing language impacts a patient’s likelihood of seeking services, including treatment for substance use disorders.  Language commonly used to talk about addiction can be judgmental, perpetuates stereotypes, and can ultimately prevent patients from disclosing their use of substances and accessing life-saving treatments.

The most important thing to remember is that addiction is a chronic medical disease, not a moral failing.

You can shift your language around addiction by using “person-centered” language. This style of language detaches the behaviors surrounding the use of substances from someone’s identity. For example, instead of saying “drug addict”, consider saying “person with substance use disorder.”

Want to learn more about person-first language?  Review “Words Matter: Preferred Language for Talking About Addiction,” from the National Institute on Drug Abuse and “Remove Stigma: Talk with Your Patients About Substance Use Disorder” from the Centers for Disease Control (CDC).

Motivational interviewing (MI) is a patient-centered approach to clinical conversations that help assist patients in finding their own reasons and motivation for change.

The method uses communication strategies such as open-ended questions, reflections, and summarization to understand behaviors and elicit change talk. MI is used to enhance intrinsic motivation to change by exploring and resolving ambivalence a patient may have about their substance use.  It is collaborative and supports an individual’s autonomy; a tool with which the clinician can seek to understand the patient’s perspective and guide them to behavioral change.  The method assists the clinician in building the patient’s awareness of the discrepancies between a patient’s desires or values and their current behaviors.

For more information on how to learn and use Motivational Interviewing, review the following resources. From the Providers Clinical Support System (PCSS): 

"Motivational Interviewing: Talking with Someone Struggling with Opioid Use Disorder".

 “Principles of Motivational Interviewing: Useful for Primary Care Providers.”

And these resources from the CDC: 

“Motivational Interviewing to Help Your Patients Seek Treatment.”

Teaching module for continuing medical education: “Motivational Interviewing.”

Unhealthy opioid, alcohol, and other substance use are among the most common causes of preventable morbidity and mortality, yet they often go unrecognized in the primary care setting despite their frequent presentation.  This can be attributed to factors such as insufficient screening and provider discomfort with managing a positive screen.  Simple tools are available to assist the provider in making screening easy and do not require complex skill, training, or a lot of time. It can start with a few questions and lead to in-office treatment or a referral to a behavioral health or addiction treatment center.  In addition, highlighting use of substances during the medical visit reinforces the negative relationship of substance use to patient health and increases awareness of what unhealthy use it.

Check out this interactive tool from the National Institute on Drug Abuse (NIDA) and the Clinical Trials Network (CTN) Dissemination Initiative to personalize and create your own screening tools: “Implementing Drug and Alcohol Screening in Primary Care.” 

Resources for patient education, pamphlets, and brochures: “Screening Toolkit.” 

Other resources to screen your patients with online calculators or fillable forms: 

• Screen severity of patient OUD and refer their patients to OUD treatment services: Screening to Brief Intervention (S2BI)
• Identify risky substance use behaviors among adolescents: Brief Screener for Alcohol, Tobacco, and other Drugs (BSTAD)
• Screen patients for frequency and severity of drug use: Drug Abuse Screen Test (DAST-10)
• Screen patients for frequency of alcohol use: Alcohol Use Disorders Identification Test (AUDIT)
  

Patients are more likely to disclose information about patient substance use if questions are open-ended and nonjudgmental (Source: Journal of General Internal Medicine). By showing your patients that you care and are concerned about their substance use, you can build trust, understand your behaviors and readiness for change, and help them engage in treatment.    

Screening, Brief Intervention, and Referral to Treatment (SBIRT) can help your patients reduce their substance use. By engaging their patients in brief, 5-10 minute conversations about alcohol, tobacco, or other substances, PCPs can help prevent progression from substance misuse to substance use disorder and help their patients struggling with substances obtain care.

Review this list of resources from the Substance Abuse and Mental Health Services Administration (SAMHSA): “Resources for Screening, Brief Intervention, and Referral to Treatment (SBIRT).” 

 Training module on the subject from the Addiction Technology Transfer Center (ATTC): “SBIRT model training.” 

Find resources to deliver brief interventions with patients with substance use disorder:

SBIRT Provider Card

SBIRT Provider Card—Spanish

Brief Intervention Guidance Sheet

Patient Goal Sheet
 

Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.  Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.

Opioid use disorder (OUD) is the chronic disease of opioid addiction and can effectively be treated with FDA approved medications such as buprenorphine, methadone, and naltrexone. Buprenorphine and naltrexone can be prescribed in the primary care setting, markedly increasing access to these life-saving medications.

There are currently three FDA-approved medications to treat opioid use disorder: buprenorphine, methadone, and naltrexone. Each of these medications are available in different formulations, allowing the provider to optimize treatment for various clinical scenarios. Research has shown that these medications prevent and reduce opioid overdoses, increase patient survival, decrease illicit use of substances, decrease criminal activity, and improve patient outcomes like maintaining employment and engaging in education. These medications improve birth outcomes in pregnant women and lower a person’s risk of contracting HIV and hepatitis C.

Buprenorphine is an opioid partial agonist, meaning that it stimulates opioid receptors, but has a ceiling effect in which increasing doses does not cause a linear increase in receptor stimulation. Because of this, it is considerably safer than full agonists and has less risk of respiratory depression and overdose. It can appropriately be prescribed in the outpatient, primary care setting.

Methadone is a long-acting, full opioid agonist that is generally prescribed at certified Opioid Treatment Programs (OTPs). Methadone treats withdrawal from opioids, reduces opioid cravings, and can block or blunt the effects of short-acting illicit opioids such as fentanyl, heroin, and oxycodone.

Naltrexone is not an opioid, but rather an opioid receptor antagonist, and works by binding and blocking opioid receptors. It very effectively prevents and reduces opioid overdoses.

Research demonstrates that treatment with MOUD, saves lives, promotes recovery, and improves patient outcomes. It is generally recommended that medications be part of a comprehensive care plan that includes counseling and behavioral therapies, as addiction is a complex medical illness that can include emotional dysregulation and dysfunctional coping mechanisms. Limited access to such behavioral health resources, however, should not be a barrier to starting patients on medications for opioid use disorder. Similarly, providers should not withhold medications from patients if they are not willing to engage in behavioral health treatment.

A multitude of policy institutes including the National Institutes of Health (NIH), the National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) highlight the abundance of research showing that methadone, buprenorphine, and naltrexone are effective treatments for OUD. These medications reduce opioid use and use disorder-related consequences to mental, physical, and emotional health. They reduce overdose deaths, reduce the risk of infectious disease transmission, decrease criminal behavior, and increase positive outcomes such as employment and economic wellness.

Research report from NIDA: “How Effective are Medications to Treat Opioid Use Disorder?” 

Resource from the Committee on Medication-Assisted Treatment for Opioid Use Disorder at the National Academies of Science: “The Effectiveness of Medication-Based Treatment for Opioid Use Disorder.” 

On December 29, 2022, Congress signed the Consolidated Appropriations Act of 2023, which ended the “DATA-Waiver Program," or what had come to be called the “X-waiver.”  In recognition of the growing crisis of substance use and addiction, the DEA announced their goal of making life-saving medications more readily available and accessible to anyone needing it. With this policy comes the following changes:

• The DATA-Waiver registration is no longer required to prescribe buprenorphine.
• All licensed practitioners, except veterinarians, who hold a DEA registration with Schedules II – V authority, and where state law allows, can prescribe buprenorphine.
• There are no longer any limits or patient caps on the number of patients a prescriber may treat for OUD with buprenorphine.

Separately, the Act does introduce new training requirements for all prescribers which went into effect June 27, 2023.  Practitioners applying for a new or renewed Drug Enforcement Administration (DEA) registration will need to attest to having completed a total of at least 8 hours of training on opioid or other substance use disorders, as well as the safe pharmacological management of dental pain.  Please see the section on “Training and Continuing Education” for a wide selection of educational resources available to fulfill this requirement.

Find answers to many frequently asked questions from SAMHSA.

Download the documents below to assist in buprenorphine prescribing practices. 

Sample office note templates:

• Office note template for various EMRs.

DSM Diagnostic Criteria:

• DSM-5 checklist for OUD diagnostic criteria. 

Sample buprenorphine treatment agreement from PCSS: 

• Version 1.
• Version 2. 

Brief guides and checklists for starting buprenorphine:

• SAMHSA’s quick start guide with COWS scale and induction algorithm.
• SAMHSA’s pocket guide with algorithm.
• Printable checklist for starting buprenorphine in the primary care office
  • SAMHSA’s “Practical Tools for Prescribing and Promoting Buprenorphine in Primary Care Settings.”

In depth clinical guidelines on buprenorphine treatment:

• ASAM’s “National Practice Guideline for the Treatment of Opioid Use Disorder.”
• SAMHSA’s “Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.” 

Watch this video for a step-by-step guide to prescribing buprenorphine: Buprenorphine Induction

Did you know? The University of Idaho’s Project ECHO (Extension for Community Healthcare Outcomes) offers twice-monthly peer-led educational webinars on substance use disorder. 

Methadone is one of the three currently FDA-approved medications shown to be a safe and effective treatment for opioid use disorder. While buprenorphine is often the recommended medication for OUD treatment, methadone may be preferred in some instances. Some studies have shown that in certain clinical populations, methadone is associated with greater retention in treatment and longer opioid abstinence. This may include patients with a higher level of physical dependence, dependence on higher potency opioids, those who are unable to tolerate buprenorphine or the naloxone in the dual-product buprenorphine/naloxone, or those who are unable to tolerate the several hours of abstinence required to start buprenorphine (in order to prevent precipitated withdrawal). 

Methadone is a long-acting opioid agonist that binds to mu-opioid receptors, thereby treating both symptoms of withdrawal from and cravings for other opioids. Patients become physically tolerant and dependent on methadone (as they do with buprenorphine), a process which reduces euphoric effects of subsequent illicit opioid use. When treated, patients are often able to escape the pattern of problematic behaviors associated with active opioid addiction and gain some normalcy in their lives.

In the United States, methadone for the treatment of opioid use disorder can only be prescribed through a federally regulated system, in clinics known as Opioid Treatment Programs, or OTPs. Here is it typically given as a liquid diluted with juice or artificially colored water, though it does also come in tablets or dissolvable diskettes. A typical starting dose is usually between 30-40mg in a single dose, with maximum initial doses allowed by federal guidelines is up to 50mg. It is titrated with an increase of 5-10mg every 2 to 3 days to an average range between 60-100mg daily, though this can vary widely from patient to patient.

See SAMHSA’s portal on methadone for more information. 

Refer your patient for treatment with SAMHSA’s OTP directory. 

Opioid use disorder in pregnancy poses substantial risks to maternal and fetal health. Maternal complications include increased incidence of hepatitis and HIV infections, increased rates of antepartum hemorrhage and placental abruption, and increased complications of mental health disorders including depression and anxiety, and increased exposure to trauma. Fetal risks include intrauterine growth restriction, preterm birth, and stillbirth. Neonates born to mothers with OUD are at risk of neonatal abstinence syndrome (NAS), leading to respiratory distress, feeding difficulties, and neurodevelopmental challenges.

Because of this heavy burden of morbidity and mortality, the general recommendation from institutions that develop trusted medical guidelines for the obstetric population, such as the American College of Obstetrics and Gynecology (ACOG), include universal screening for substance use and treatment for OUD with opioid agonists methadone and buprenorphine. For women who are established on these MOUDs and become pregnant, it is generally recommended that they remain on their medications during pregnancy rather than wean or discontinue.  In the absence of other contraindications, such as HIV infection and continued illicit substance use, breastfeeding should be encouraged in women who are on MOUDs.

General guideline recommendations:

• Universally screen for substance use during a first prenatal visit.
• Provide a brief intervention using Motivational Interviewing to engage the patient in discussion on substance use and risks of SUDs.
• For pregnant women with OUD, use shared decision making to develop a plan of care for treatment.
• Pharmacological management with opioid agonist medications buprenorphine and methadone is recommended as first-line treatment.
• Medically supervised withdrawal from buprenorphine and methadone is not generally recommended as it is associated with high relapse rate, increased death rates, and poorer outcomes.
• Breastfeeding should be encouraged in women who are stable on MOUDs.
• Access to psychosocial support and behavioral treatment programs should be provided, though lack of participation in such services should not prevent treatment with MOUDs.
•  

Review these resources for additional information:

• “Opioid Use and Opioid Use Disorder in Pregnancy,” an opinion from the Committee on Obstetric Practice of the American Society of Addiction Medicine, developed by the American College of Obstetricians and Gynecology. 

Explore this comprehensive guideline for treatment of pregnant women from SAMHSA: 

• “Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants.” 

Offer your patients these helpful SAMHSA brochures for education and support:

• “Opioid Use Disorder and Pregnancy.”
• “Treating Opioid Use Disorder During Pregnancy.”
• “Treating Babies Who Were Exposed to Opioids Before Birth.” 
• “Good Care for You and Your Baby While Receiving Opioid Use Disorder Treatment.” 

The increasing public investment in drug diversion programs highlights the expanding understanding that those with the disease of addiction are more effectively served with mental health services, treatment, and rehabilitation rather than with incarceration, both for individuals as well as their communities.  Programs such as Drug Court and the Idaho Law Enforcement Diversion Program are designed to provide individuals charged with drug-related offenses an alternative to traditional criminal prosecution and have been shown to effectively reduce criminal activity, reduce recidivism, increase community safety, and lead to improved outcomes.

Prior to our modern understanding of the disease model of addiction, substance use has traditionally been aggressively criminalized which led to a high incarceration rate of those with substance use disorders.  Rates of opioid use disorders among those involved in the criminal justice system are thus disproportionately high.  Those persons with OUD who remain untreated while incarcerated have a higher risk of opioid related death upon release and, according to studies, are most likely to be rearrested for behaviors related to their continued illness.

Though the effectiveness of pharmacological treatment with MOUDs is well established, these medications are not commonly provided to those in correctional settings in the United States. According to Cates and Brown in Medications for opioid use disorder during incarceration and post-release outcomes, “not only is forced withdrawal extremely uncomfortable to endure but it is also associated with an increased risk of opioid-related overdose after release” (see reference below).  In fact, it is the position of the National Commission on Correctional Health Care that providers in correctional settings follow ASAM guidelines when treating people with OUD and have affirmed the “right of people with OUD in jails and prisons to receive MOUD.”

Because of these compelling reasons, it will be of benefit to develop, implement, and improve programs that increase access to MOUDs in those currently incarcerated.

For further information, review these articles:

“Medications for opioid use disorder during incarceration and post-release outcomes,” Cates, L., Brown, A.R. Health Justice 11, 4 (2023).  

“Opioid Use Disorder Treatment in Correctional Settings.” A position statement by the National Commission on Correctional Health Care, 2021. 

“Part 12: Special Populations: Individuals in the Criminal Justice System,” in The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder, from the American Society of Addiction Medicine, 2020. 

• Find a buprenorphine practitioner in your area with SAMHSA’s buprenorphine practitioner locator.
• If your patient is interested in methadone treatment, refer them to a local Opioid Treatment Program.
• Use SAMHSA’s comprehensive treatment directory to find treatment options including residential in-patient treatment, partial hospitalization services, intensive outpatient treatment, detox facilities, and treatment for co-occurring substance use and mental health illness. 

Use these resources to get answers:

• University of Idaho’s Project ECHO: Two to three times monthly, ECHO provides a “Curbside Consult for Opioid & Substance Use Treatment,” an online interactive space, staffed by experts in the field, where anyone can ask questions and discuss particular clinical situations, patients, or medications. 

   

• The Substance Use Warmline: free and confidential clinician-to-clinician telephone consultation through the National Clinician Consultation Center at (855) 300-3595.  Consultation is available Monday through Friday, 9am-8apm ET, from addiction medicine-certified physicians, clinical pharmacists, and nurses with special expertise in pharmacotherapy options for opioid use.

   

• SAMHSA’s National Helpline: free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders at 1-800-662-HELP (4357).