Substance use disorders (SUD) are common but underdiagnosed. According to the 2022 National Survey on Drug Use and Health, approximately 48.7 million Americans aged 12 or older had a SUD in the past year, yet only about 6% received treatment. That same report found that approximately 21.5 million adults in the US have co-occurring mental health and substance use disorders.1 The good news is that all health care providers can help improve care for patients with SUDs by effectively screening and incorporating treatment for these conditions into their practice. Engaging patients early in the disease process can reduce morbidity, mortality, and healthcare costs and is most effective when providers use a compassionate, nonjudgmental style.
SCREENING MATTERS
The U.S. Preventive Services Task Force (USPSTF) recommends that all adults be screened for unhealthy substance use.2 Screening should be universal and not based solely on clinical suspicion, which can be biased and miss patients who need our help. A variety of tools with validation can be administered prior to the encounter with the provider, allowing for further discussion if the screen was positive. The following screeners, except the DAST, are publicly available, free to use and can be found on the PCL website Resources page.
Alcohol Use Disorders Identification Test (AUDIT)
- AUDIT-C: A brief, validated 3-question screen that identifies hazardous drinking patterns that may be impacting physical health (e.g., hypertension, liver function) and to create an opening for brief intervention and counseling. It can be helpful for fast, universal screening during annual check-ups or new patient visits.
- AUDIT: If the AUDIT-C is positive, the full 10-item questionnaire is a good follow-up to gather more information on levels of consumption, signs of dependence, and alcohol-related problems. Because alcohol use can mimic or worsen psychiatric symptoms like depression, anxiety, and insomnia, use of the AUDIT can help clinicians differentiate symptoms, inform diagnosis, and aid in treatment planning. It is also highly regarded for its reliability and validity across diverse populations.
Drug Abuse Screening Test (DAST)
- DAST-10: A 10-question screen that assesses the degree of problems related to drug use. The DAST is a “yes/no,” self-report questionnaire that can be administered by a healthcare professional or completed by patients. It only takes 5 to 10 minutes to complete and screens for problems related to the use of illicit drugs, as well as the misuse of prescription or over-the-counter drugs.
The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
- ASSIST: A more detailed tool with 2 to 8 questions (more depending on how many substances the patient is using) that screens for nicotine, alcohol and other commonly abused substances. It is used when a patient has screened positive on a briefer tool or when you suspect polysubstance use. The ASSIST should be completed with the patient and provider together to review the tool generated substance-specific risk score andbuilt in patient education. It also helps clinicians consider the best level of intervention: brief advice in-clinic or referral to a specialist for higher-risk use.
FROM SCREENING TO ENGAGEMENT
If a patient does screen positive, the style in which the patient is engaged in discussion about diagnosis and treatment is critical to engaging patients successfully in care. Motivational interviewing (MI) is a patient-centered communication style that enhances engagement by expressing empathy, supporting self-efficacy, and avoiding confrontation. MI can help you engage with patients who are not yet expressing interest in change or are contemplating it.
Key MI techniques include using (OARS):
- Open-ended questions – invite more than a “yes” or “no” answer and encourage elaboration. “Can you tell me what you enjoy about using alcohol?” “Can you tell me more about why you are worried about your alcohol use?”
- Affirmations – Recognize and acknowledge your patient’s strengths, efforts, and intentions. “You are understandably concerned about how alcohol is impacting your health.”
- Reflective listening – Demonstrate that you have heard and understood your patient’s perspective. “You’re worried that stopping might affect your ability to cope with stress.”
- Summarizing – Periodically gather together what your patient has said, showing that you are listening carefully and helping them integrate their thoughts. “You are interested in reducing your drinking but total abstinence from alcohol is not your goal.”
MI techniques can be highly effective in helping the patient resolve their own ambivalence about their use while increasing motivation to change behavior. It also helps patients feel heard and not judged which is important for ongoing engagement in care. Further, MI improves both patient satisfaction and outcomes while improving provider well-being through better patient-provider relationships, more effective interactions, and reduced stress.3
TREATMENT CAN START IN PRIMARY CARE
Treatment of SUD in primary care settings is effective, even when severe disorders are present. For instance, primary care-based buprenorphine treatment has previously been shown to be effective in treatment patients with OUD with similar outcomes in terms of treatment engagement to subspecialty care.4 All health care providers can help reduce the burden of substance use disorders. Universal screening, empathetic communication, and medical treatment can save lives and transform the trajectory of patients struggling with substance use.
YOU’RE NOT ALONE – THE PCL IS HERE TO HELP
Supporting patients with substance use or co-occurring disorders is a team effort. If you have questions about how to screen, engage, or treat your adult patients with these or any other behavioral health conditions, please call the PCL. We are here to help!
Prescribing providers may call any time, 24/7, and non-prescribing providers may call Mon-Fri, 8 AM – 5 PM (excluding holidays) at 877-927-7924 (877-WA-PSYCH) or schedule ahead at a time that is best for you.
AUTHOR
Dr. Jonathan Buchholz is an Addiction Psychiatrist at the Veteran’s Administration, Puget Sound, and is the Director of the UW Department of Psychiatry and Behavioral Sciences Addictions Psychiatry Fellowship program. He is also the lead MD for the PCL’s Medication for Opiate Use Disorder expansion.
References
- SAMHSA. 2022 National Survey on Drug Use and Health (NSDUH).
- U.S. Preventive Services Task Force. Screening for Unhealthy Drug Use. JAMA. 2020;323(22):2301–2309.
- Pollak, K. I., et al. (2016). Effect of teaching motivational interviewing via communication coaching on clinician and patient satisfaction in primary care and pediatric obesity-focused offices. Patient education and counseling, 99(2), 300-303.
- Xu KY, Gertner AK, Greenfield SF, Williams AR, Grucza RA. Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims. Addict Sci Clin Pract. 2024;19(1):17.
RELATED RESOURCES
UW Psychiatry and Addictions Case Conference (PACC)
Should I Use Benzodiazepines for Ambulatory Alcohol Withdrawal Management? by Lucy Liu, MD
Helping Patients Get to and Utilize Twelve-Step Programs by Richard Ries, MD
Discussing Cannabis Use with Clients or Patients by Jason Kilmer, PhD
UW Addictions, Drug and Alcohol Institute (ADAI)
Retention Toolkit: Motivational Interviewing Trainings and other information on MI
Substance Use Resources in Washington State for Professionals/Providers A curated selection of resources and information for professionals and providers in the substance use disorder field.