The most important goal in a high risk substance using patient is to develop a trusted relationship with them. Stigma is high for mental health care and substance use disorders, the one with higher stigma varies by individual they can be drastically different. Overcoming stigma gives you an opportunity to implement a life saving intervention.
DO NOT ASK THEM TO STOP USING DRUGS.
DO NOT ASK THEM WHY THEY HAVEN’T STOPPED USING DRUGS YET.
What are your beliefs around the origin of substance use disorders?
Four possible angles to take with substance using patients (order of importance):
- Harm reduction focus – aiming to identify risks of death due to overdose from highest risk accidental overdose via drugs/substances.
- What drugs/substances do you like to use?
- “Do you use meth,cocaine,pills,heroin, fentanyl, use of any powder drugs, or drugs obtained online?”
- CRITICAL Administer Harm Reduction Interventions Now!! At minimum offer Narcan.
- What drugs/substances do you like to use?
2. Screening of motivations behind substance use – each are a percentage of motivation.
- Self-medication for physical/mental distress, performance enhancement, recreational use (to get high). “How do drugs help you?” This is not to work on these motivations, but to see if there is an underlying mental health disorder, unevaluated life concern.
- example: I am 70% self-medicating(what symptoms?), 30% recreational.
- *Trust/Trigger ALERT* Evaluation for and diagnosis of recreational use or mild/moderate/severe substance use disorder. (Substance Use Survey) “How often do you use? How’s your cocaine use going?…. Any issues?” “Why not use more alcohol?”
- Listen for presence of “Change Talk.”
- Before any in-depth suggestion of formal reduction/cessation of substance use.
- Remember: Safer use is the #1 form of treatment. Safer use is acceptable by 95% of drug users. Safer use can and should be offered by all care providers to try to save a life.
There are two forms of treatment for substance use disorders –
- inpatient (10 days detox with or without an added on longer term residential treatment) and
- outpatient (Integrated treatment program HHCLA, La Cada, 12 step programs, religious programs)
- (All sites should try to offer some medication strategies. Some sites actively prohibit or refuse patients the ability to use medications for addiction support.)
Balance: How do you balance time? Many patients are seeking mental health services. How do you address both issues? Focus on creating a relationship and doing harm reduction (narcan/drug testing). If they keep wanting to reference their substance use disorder and you don’t feel comfortable, let them know you can coordinate care for them. The most important thing to mention is there are a lot of new medications that can be very helpful to them in navigating their substance use.