Let's Talk About Substance Use

It can be daunting to ask your patients about substance use. Below are some strategies for navigating patient conversations about substance use:

•  Ask permission to ask sensitive information
  • Example:
    • Would it be alright with you if I asked you some questions about your substance use? 
• ​​​​​​​Normalize the conversation
  • Examples:
    • This is not unusual. Many patients find it hard to talk about their substance use…
    • Talking about substance use can be uncomfortable.
• Ask specific questions
  • Examples:
    • Can you tell me about your street drug use?
      • Tell me about your use of marijuana.
      • Tell me about your use of cocaine. 
    • How would you describe your substance 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 information with me
    • I appreciate you trusting me with this information. 
• Let patients know that your questions are standard, asked the same way for all patients
  • ​​​​​​​Example: 
    • ​​​​​​​​​​​​​​I ask all of my patients very specific questions about their use of [XXX] 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 appropriately
  • ​​​​​​​Example: 
    • ​​​​​​​My goal is to respect your privacy while abiding the protections provided by law for patients. 

(Sources: CDC and PCSS)

To learn more strategies for navigating conversations with patients about their substance use, check-out the CDC’s Conversation Starters pamphlet and the PCSS Quality Medical Care for PWUD 

Stigmatizing language can impact patients’ likelihood of seeking healthcare services, including substance use disorder treatment.  Language commonly used to talk about addiction is often judgmental, perpetuates stereotypes, and can ultimately prevent patients from disclosing their substance use and accessing care.

The most important thing to remember is that substance use disorder is a chronic disease, not a moral failing. Factors that increase vulnerability to addiction include:

• Family history. Genetics and child-rearing practices can predispose someone to addiction.
• Early exposure to drug use. Adolescents are especially vulnerable to addiction.
• Exposure to high-risk environments. Trauma, including stressful environments with poor familial and social supports, increases risk of addiction.
• Mental illnesses. Mental health disorders can increase the likelihood of substance use and addiction.

Just as these factors contribute to the determination  of a person’s unique susceptibility to using drugs initially, they also contribute to the susceptibility to sustaining drug use and undergoing the progressive changes in the brain that characterize addiction (Source: The New England Journal of Medicine).

The easiest way to shift your language around substance use is to use “person-centered” language. This style of language detaches the substance use from someone’s identity. For example, instead of saying “drug addict”, consider saying “person with substance use disorder”. This re-phrasing can separate the patient from their disease and takes the blame off of them.

Want to learn more about person-first language? Select the link to access free CME activities through NIDA. 

• Familiarize yourself with screening tools
  • There are several evidence-based screening tools for substance use. These tools can help to start the conversation about substance use and treatment options.
    • ​​​​​​​Select the link to access the Screening and Assessment Tools Chart
• Select screening and assessment tool(s)
  • ​​​​​​​Screening, brief interventions, and referrals to treatment have been effective in managing substance use, especially among pregnant patients. This process is known as the SBIRT model, which is easy to follow and integrate into your practice. 
• Learn how to prescribe buprenorphine 
  • ​​​​​​​Buprenorphine is a life-saving medication for opioid use disorder.  Buprenorphine treats withdrawal symptoms and cravings for opioids, leading to a reduction in opioid use.  As a partial opioid agonist that has a ceiling effect and binds very tightly to the opioid receptors, buprenorphine can prevent opioid overdose and death.
  • Did you know? In December 2022, with the signing of the Consolidated Appropriations Act of 2023 (the Act), Congress eliminated the "DATA-Waiver Program." As a result, providers do not need to register for the DATA-Waiver to prescribe buprenorphine. Select the link to learn more about the elimination of the DATA 2000 X-Waiver
• Create a list of behavioral health and treatment providers for referrals
  • ​​​​​​​Reducing barriers to prescribing buprenorphine will help increase access to this life-saving medication for OUD, but it is still important for providers to know the  behavioral health and addiction medicine experts in their community, from whom they can seek help if needed.
    • Although patients should not be required to pursue behavioral health treatment in order to obtain their prescription for buprenorphine, many patients with OUD and other SUD will benefit from behavioral health treatment.  Know the providers in your community so that you can facilitate timely referrals when appropriate.
      • Did you know? Optum Idaho has regional field care coordinators to direct healthcare providers and members to behavioral health services. Select the link to find your regional field coordinator’s contact information.
• Include screening within the clinical workflow
  • ​​​​​​​Work with your administrators and clinical team to add screening for substance use into your team’s workflow; building screening tools for SUD into medical assistant or nursing workflows may decrease time constraints for providers.​​​​​​​

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 worried about their substance use, you can build trust, better understand your patient’s substance use and readiness for change, and help them engage in treatment if interested.    

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.

​​​​​​​Select the link to access an SBIRT model training. ​​​​​​​

Motivational interviewing (MI) is a patient-centered approach to clinical conversations.

MI uses communication strategies such as open-ended questions, reflections, and summarization to understand patient substance use behaviors and elicit change talk. 

Learn more about MI and how you can integrate it within your clinic through the PCSS Motivational Interviewing Guide

Find resources to screen your patients for opioid use disorder, opioid withdrawal, and social and medical histories below: 

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)

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

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

Select the link to learn more about opioid use disorder

Currently, there are three FDA-approved medications available to treat OUD—buprenorphine, methadone, and naltrexone.

Buprenorphine and methadone are life-saving medications. These medications control opioid cravings and withdrawals. In addition, buprenorphine and methadone reduce the rate of opioid use and risk of overdose and complications with opioid use.

Buprenorphine is a safe and effective medication for patients with opioid use disorder and can be prescribed within a primary care setting. Buprenorphine is a partial agonist and has a ceiling effect—once the patient reaches a certain dosage level, the patient will not receive additional benefits and will not be at risk for respiratory depression.

Methadone is a full agonist opioid that are dispensed through opioid treatment programs. Methadone may be a great option for patients that do not feel that their needs are being met with buprenorphine.

Select the link to learn more about medications for opioid use disorder

Medications for opioid use disorder (MOUD) have shown to improve patient survival, increase retention in treatment, decrease illicit opioid use, and criminal activity among people with OUD. MOUD increases patients’ ability to gain and maintain employment and improves birth outcomes among persons who have OUD and are pregnant. As well, MOUD reduces patients risk of acquiring HIV and hepatitis C (Source: SAMHSA).

Research demonstrates that treatment with MOUD alone, specifically methadone or buprenorphine, saves lives and promotes recovery. Limited access to behavioral health resources 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 interested in behavioral health treatment. Select the link the full research article. 

In December 2022, with the signing of the Consolidated Appropriations Act of 2023 (the Act), Congress eliminated the “DATA-Waiver Program.” According to the DEA, the DATA-Waiver registration will no longer be required to treat patients with buprenorphine for opioid use disorder.

 With the elimination of the X-Waiver, providers should be aware of the following information:

• All prescriptions for buprenorphine only require a standard DEA registration number. The previously used DATA-Waiver registration numbers are no longer needed for any prescription.
• There are no longer any limits or patient caps on the number of patients a prescriber may treat for opioid use disorder with buprenorphine.

The Act does not impact existing state laws or regulations that may be applicable. In addition, the Act also introduced new training requirements for all prescribers. Select the link to learn more about the elimination of the X-Waiver

Please note: Limited guidance for providers has been published upon the elimination of the X-Waiver. The Department will update information on this webpage, once published. 

Download the documents below to assist in buprenorphine prescribing practices: 

Buprenorphine Quick Start Guide

Sample Buprenorphine Consent Form (Courtesy of Marimn Health)

Checklist for Buprenorphine Induction (Courtesy of Marimn Health)

PCSS MAT Guidance for Buprenorphine Induction

Sample Clinical Induction Protocol

Sample Opioid Use Disorder Primary Care Pathway 

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. Select the link to learn more about Project ECHO Idaho