How do you talk with patients about their substance use?

You log in to Zoom for the morning clinic video visits and meet Zeke, a 28 yo man without much medical history, here to establish care with you. As he’s sharing his daily routine, Zeke says that after work–he’s a 4th grade teacher–he comes home so overwhelmed with what’s going on for his students that he opens a bottle of wine to relax. On really tough days, he’ll finish the whole bottle by himself. You appreciate that Zeke felt comfortable sharing; you hope to continue cultivating a welcoming space for the discussion and wonder where to go from here.

Conversations about substance use can be hard especially when there’s limited time. Let’s discuss the “how” of this conversation first, including some useful wording to help patients feel welcome and respected and then introduce the “RIP-TEARframework to structure the content of the conversation. The chart below highlights 3 important components in starting this conversation.

Example wordingReason
Non-punitive,
Non-judgmental,
Welcoming Attitude
“Can you tell me more about your day to day right now and how the alcohol fits in?

“What does alcohol do for you? How does it help you? How does it not benefit you?

“At our clinic, we take care of all our patients, no matter what.”
It’s important to normalize that substance use is something you discuss with all your patients and is not punished in your clinic. Share that you would like to explore the role the alcohol plays in the patient’s life.

Signal to your patients that they are entering a non-punitive space with signs in the clinic or in your initial conversation.
Non-stigmatizing,
Person-first Language
“You are concerned about your alcohol use; it’s causing problems for you.”

“You used the word alcoholic to describe what you hope you’re not becoming. You also shared with me that you are more than the alcohol use; though, right now, it seems to be causing a lot of chaos in your life.”
Words matter. You listen to the words the patient uses to refer to their substance use, to themselves, while drinking, and to the drinking experience overall.

Healthcare worker verbiage should avoid words like “addict,” “alcoholic,” or “alcohol abuse,” even if the words are used by a patient or loved ones. Use person-first language, like “patient with problematic or chaotic substance use” or “patient with substance use disorder.” Using accurate, non-stigmatizing language is of particular importance when writing in a patient’s chart.
Acknowledgement that the Patient is the Expert in their own Experience“Would it be okay if we talked a bit about cocaine use?”

“I’m asking these questions about the substances you use because I want to help with your primary concern or XYZ issue.”

“Can you tell me how you inject substances?”

“Do you plan to increase, maintain, or decrease your current level of use?”
Ask permission to discuss substance use, explain why you are asking about substances, and provide space to learn from patients.

Open-ended questions and curiosity about the patient’s story, goals, hopes and worries will help you learn about who they are and eventually inform treatment decisions.

In the non-judgmental and welcoming space you’ve created, you can use Dr. Jeanette Tetrault’s RIP-TEAR framework and wording to guide your visit and conversation with the patient.

RIP-TEAR stands for RISK-INITIATION-PATTERN — — TREATMENT EPISODESEFFECTSABSTINENCERETURN TO USE

RISK: Identify imminent risks to a patient’s health up-front, including overdose risk from an unpredictable and potent drug supply. If the patient is in a vulnerable state due to pain, withdrawal, or risk for withdrawal, address that before delving into a conversation.

INITIATION: Once imminent risks are identified and addressed, we can ask further questions. When did the patient first begin using substances – of any kind – and under what circumstances? This gives us a sense of the length of time, the role of substances, and the intensity with which substances have been a part of the individual’s life. Understanding what has driven a patient’s substance use influences how we speak with patients and helps us in treatment planning.

PATTERN: It’s important to understand the current patterns in patients’ substance use (e.g. route of use, quantity, frequency, temporal patterns) to recognize triggers, evaluate the potential for withdrawal symptoms, and identify options for harm reduction.

TREATMENT EPISODES: What are the patient’s past experiences with treatment for substance use? If a patient tells you treatment was unsuccessful (“I used disulfiram for alcohol in the past, and it didn’t work for me”), find what didn’t work (“What was the issue with taking disulfiram?”). Sometimes patients inaccurately correlate a struggle or concern with a given treatment (i.e. patient identified disulfiram as causing anxiety, when anxiety was more likely due to alcohol cessation). Understanding past treatment episodes helps frame current treatment options in the context of the patient’s hopes and concerns. 

EFFECTS (Positive and Negative): Ask about both the positive and negative effects of substance use. If you already asked this question earlier in the conversation, this can be a nice opportunity to summarize and reflect back what a patient has shared about their relationship with a substance (including how the substance has helped them). This summary can help the clinician and patient elicit the patient’s goals.

ABSTINENCE: While abstinence is not every patient’s goal (or the only outcome in treatment), asking about past periods of abstinence can help clarify how they felt during periods of non-use. Moreover, clarifying the patient’s goals (“what are your plans relative to the alcohol: increase, continue use, or reduce?”) can also help paint a picture of the future the patient envisions for themselves, including whether abstinence (or another goal for the substances) is a part of that future.

RETURN TO USE: What risks or triggers may cause patients to return to use or return to chaotic, unsafe, or unstable situations? Anniversaries of loved ones’ deaths, job loss, interactions with a particular friend, or other specific situations could be relevant and difficult for individuals using substances. Exploring these areas can help clinicians make a treatment plan with the relevant tools and support.

In talking to Zeke, you find out that he is drinking alone at night, usually after skipping a meal, and drinking above healthy limits about three times a week. As part of your RIP-TEAR history approach, you learn that he started drinking in college because it calmed him down at parties. He’s actually reduced his use in the past (early 20’s) when he didn’t like feeling hungover after a weekend bar-hopping. He says stress is what makes him start back up, drinking more than he wants, especially when he has a lot of lesson planning to do for his students. This last month, when he’ll occasionally drink a bottle at night, Zeke says he hasn’t had any problems with his relationships or any other consequences of his alcohol use; he just doesn’t like feeling tired the next day. Zeke says the wine initially helps him relax and sleep, but overall, he’s noticed the whole bottle of wine is not really doing him any favors. In clarifying his goals, Zeke says he doesn’t want to stop drinking entirely but hopes to cut back and try to be healthier.

In Zeke’s case, he doesn’t have alcohol use disorder (AUD) on your assessment, but he wants to take a healthier–harm reduction–approach to his drinking. You offer the safer-use strategy sheet of harm reduction tips for alcohol use from the University of Washington. In reviewing the suggested strategies, Zeke decides that he can eat before drinking, space out the glasses of wine, and drink water instead of the wine while he’s cooking. You plan to follow-up with him in a month to check-in on his progress towards these goals.

References 

Harm Reduction for Alcohol Use document: For more information, contact the Harm Reduction Research and Treatment Center at harrtlab@uw.edu.

Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010 May;21(3):202-7. doi: 10.1016/j.drugpo.2009.10.010.

https://thecurbsiders.com/addiction-medicine-podcast/3-harm-reduction-partnering-with-patients

https://thecurbsiders.com/addiction-medicine-podcast/8-back-to-basics-a-stigma-free-history

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