Patient Communication in Substance Use Disorders

Open with the patient’s priorities rather than a demand for abstinence: ask what they value, what concerns them about current use, and what outcome they would consider worth pursuing today. State that the visit can address safer use, reduced use, abstinence, medication treatment, withdrawal concerns, or linkage to care. A client-driven goal process is consistent with motivational interviewing, and matching patients to preferred substance use disorder treatment options can improve alcohol and drug-related outcomes. PubMedPubMedChapter 6—From Preparation to Action: Initiating Change - Enhancing Motivation for Change in Substance Use Disorder Treatment - NCBI Bookshelf

Use person-first language, including “person with opioid use disorder,” “person who uses drugs,” and “substance use disorder,” rather than labels such as “addict,” “abuser,” or “clean/dirty.” Healthcare professionals’ negative attitudes toward addiction can adversely affect service delivery, whereas knowledge dissemination and respectful language are identified strategies to counter stigma in clinical settings. ScienceDirect+1ScienceDirectA systematic review of stigma interventions for providers who treat patients with substance use disordersIDSAPrimary Care Guidance for Persons With HIV

When trauma, prior coercive treatment, discrimination, or mistrust may be affecting engagement, make the encounter explicitly collaborative: explain choices, ask permission before sensitive questions, offer options rather than ultimatums, and identify what would make treatment feel safe. Trauma-informed care emphasizes shared decision-making, trust, empowerment, and culturally and linguistically appropriate care. PubMedPubMedThe Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder

Motivational interviewing is a collaborative, goal-oriented communication style that focuses on change language. Its purpose is to strengthen personal motivation and commitment by exploring the patient’s own reasons for change and resolving ambivalence in an accepting, compassionate interaction. PubMedPubMedMotivational interviewing for substance use reduction - PMC

Prioritize four actions: express empathy, develop discrepancy between the patient’s goals and the effects of use, avoid argument or confrontation, and support self-efficacy. Motivational enhancement therapy uses these motivational interviewing techniques while monitoring progress toward patient-expressed goals. PubMedPubMedEARLY INTERVENTION, TREATMENT, AND MANAGEMENT ...

Listen for both change talk and sustain talk. When a patient says, “I know methamphetamine is affecting work, but it is the only way I can function,” reflect both sides before advising: “Work matters to you, and you are worried the current pattern is costing you the stability you want.” Then ask an evoking question: “What would be different if use were less in control of your workday?” This approach is designed to guide rather than impose an expert conclusion. ScienceDirect+1ScienceDirectMotivational Interviewing - an overviewPubMedMotivational interviewing for substance use reduction - PMC

End a brief intervention with a concrete, patient-selected plan rather than an open-ended recommendation. The plan can be a treatment appointment, a medication conversation, a recovery-support contact, a harm-reduction step, or a follow-up visit to reassess readiness. Brief interventions using motivational interviewing can be delivered by trained healthcare personnel, including in integrated HIV care settings. IDSA+1IDSAPrimary Care Guidance for Persons With HIVPubMedChapter 6—From Preparation to Action: Initiating Change - Enhancing Motivation for Change in Substance Use Disorder Treatment - NCBI Bookshelf

Present treatment as a menu linked to the patient’s stated goal: medication, counseling, contingency management, recovery support, care coordination, or a combination. Explain the expected target of each option and ask which option feels acceptable now. Client-driven goal clarification and matching to preferred treatment options can reduce alcohol consumption and improve drug-related outcomes. PubMedPubMedChapter 6—From Preparation to Action: Initiating Change - Enhancing Motivation for Change in Substance Use Disorder Treatment - NCBI Bookshelf

For opioid use disorder, explicitly discuss medication treatment rather than limiting the conversation to counseling or referral. Medication is described as the most effective treatment and standard of care for opioid use disorder, and hospitalized care models that improve treatment initiation address opioid use, withdrawal, pain, psychosocial issues, overdose prevention, and linkage to post-discharge care. PubMed+1PubMedChapter 3—Counseling Approaches for Promoting Harm ...PubMedThe Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder

When the patient declines a recommended option, identify the specific barrier: fear of withdrawal, prior adverse treatment experience, cost, transportation, confidentiality, housing instability, legal concerns, family conflict, or concern about stigma. Respond by modifying the access plan rather than interpreting refusal as lack of motivation. Trauma-informed approaches emphasize empowerment and trust, while integrated models use motivational interviewing, psychoeducation, harm reduction, and case-management support to address ambivalence and disempowerment. PubMedPubMedThe Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder

Use family involvement only with the patient’s permission and when it supports the patient’s goals. For adolescents and young adults with alcohol use or alcohol use disorder with or without other drug use, guideline-supported options include non-brief motivational interviewing, family therapy, and cognitive-behavioral therapy. ScienceDirectScienceDirectClinical Practice Guideline: Assessment and Treatment of Adolescents and Young Adults With Substance Use Disorders and Problematic Substance Use (Excluding Tobacco)

Contingency management provides incentives contingent on a predefined behavior. It is among the most effective behavioral interventions for problematic substance use and is used most often for stimulant recovery, including cocaine, methamphetamine, and prescription stimulant use, although it can be used for other substances. PubMedPubMedChapter 3—Counseling Approaches for Promoting Harm ...

Specify the target behavior before enrollment: treatment attendance, medication adherence, toxicology-confirmed abstinence, engagement in prosocial activities, or another recovery behavior. Contracts and reinforcement schedules are commonly used in programs that employ contingency management; incentives may reinforce substance-free toxicology results or other agreed targets. PubMed+1PubMedChapter 6—From Preparation to Action: Initiating Change - Enhancing Motivation for Change in Substance Use Disorder Treatment - NCBI BookshelfPubMedContingency Management: Using Incentives to Improve ... - PMC

Use contingency management as a complement rather than a replacement for patient-centered counseling. Motivational interviewing relies on intrinsic motivation, whereas contingency management relies on extrinsic incentives. Both approaches can reduce use across a range of substances; evidence summarized in motivational treatment guidance suggests extrinsically focused strategies may have shorter-term effects, while intrinsic motivation may be more important for maintaining behavior change. PubMed+1PubMedChapter 3—Counseling Approaches for Promoting Harm ...PubMedChapter 7—From Action to Maintenance: Stabilizing Change - Enhancing Motivation for Change in Substance Use Disorder Treatment - NCBI Bookshelf

For patients receiving cognitive-behavioral therapy, consider whether a program can combine motivational enhancement, contingency management, and cognitive-behavioral skills work. Motivational strategies at the beginning of cognitive-behavioral therapy can improve motivation and retention, and studies of combined cognitive-behavioral therapy plus contingency management have found greater abstinence after treatment. PubMedPubMedChapter 3—Counseling Approaches for Promoting Harm ...

At each follow-up, review the action selected at the prior encounter, not only the amount of substance used. Ask whether the patient was able to start the chosen treatment, what barriers emerged, whether the goal remains meaningful, and whether the plan needs to change. Motivational approaches support ongoing monitoring of progress toward patient-expressed goals. PubMed+1PubMedEARLY INTERVENTION, TREATMENT, AND MANAGEMENT ...PubMedChapter 6—From Preparation to Action: Initiating Change - Enhancing Motivation for Change in Substance Use Disorder Treatment - NCBI Bookshelf

Respond to recurrence of use with a reassessment of triggers, treatment fit, access barriers, and safety needs rather than a discharge-oriented conversation. Relapse-prevention counseling focuses on identifying and managing triggers, developing coping skills, strengthening self-efficacy, and managing setbacks. PubMedPubMedChapter 7—From Action to Maintenance: Stabilizing Change - Enhancing Motivation for Change in Substance Use Disorder Treatment - NCBI Bookshelf

Build communication capacity at the practice level. Provider-stigma interventions have included online education, in-person education, communication training, mentorship, and contact with people in recovery; higher-quality studies incorporated motivational interviewing or communication training, and consumer-contact interventions demonstrated longer-term effects. ScienceDirectScienceDirectA systematic review of stigma interventions for providers who treat patients with substance use disorders

Where substance use intersects with chronic disease care, integrate rather than silo the conversation. In HIV care, integration of substance use treatment with HIV care is considered ideal, and trained personnel can provide brief interventions that include motivational interviewing. IDSAIDSAPrimary Care Guidance for Persons With HIV