Recommendations published in 2009 for chronic opioid therapy based on a review of the evidence. Provide guidance on patient selection, risk stratification, informed consent, opioid management plans, and more. Authors: Chou R, Fanciullo GJ, Fine PG, et al.
Resource Type: 
NIDA created a "clinician's screening tool for drug use in general medical settings"
Resource Type: 
The NIDA quick screen is an online screening tool for substance abuse filled out by the patient. Based on the patient's responses, it generates a substance involvement score that suggests the level of intervention needed. This is the short, online version of the longer screening tool, the NIDA Modified ASSIST.
Resource Type: 
The NM ASSIST (NIDA-Modified Alcohol, Smoking, and Substance Involvement Screening Test) clinicians through a short series of screening questions and, based on the patient's responses, generates a substance involvement score that suggests the level of intervention needed.
Resource Type: 
This screening tool guides clinicians through a short series of questions and generates a substance involvement based on the patient's responses. A link to the NIDA Quick Screen version is available online on this page as well as a link to the longer, NIDA-Modified ASSIST for printing. The tool also provides links to resources for conducting a brief intervention and treatment referral.
National Institute on Drug Abuse
Resource Type: 
Resources for medical and health professionals on drug abuse and addiction, including general information, treatment and prevention, clinical tools, and a screening tool. Resources for patients are also available, including information in Spanish.
National Institute on Drug Abuse

Here is a summary of recommended skills, organized by core competencies:

Provide patient-centered care

  • Use the communication skills learned for brief interventions including using a patient-centered approach, for example, providing information, encouragement, and empathy.
  • Help motivate the patient to follow through with a referral to treatment for substance use disorder by
    1. Scheduling the referral appointment for them while they are in your office
    2. Providing encouragement
    3. Educating the patient about how the treatment program works and its benefits
  • It is important to be familiar with how HIPAA relates to substance use issues and to know the applicable exceptions. Further restrictions are in place with respect to health information exchange systems.
  • Some patients may benefit from an addiction treatment center that addresses the needs of special populations, such as centers that speak a particular language or that focus on specific age groups.
  • Follow up after making a referral is essential in order to help keep patients motivated to follow-though, to learn the current status of the specialty treatment, and to learn whether a different referral is needed. Make repeat referrals as needed.

Work in interdisciplinary teams

  • Consider the level of treatment the patient needs: residential or inpatient treatment, outpatient treatment, and/or local support groups.
  • Referrals may be needed for both medical/detoxification and psychosocial needs. Counseling is typically included in treatment programs, but patients needing a lower level of care may be referred directly to substance use counseling.

Employ evidence-based practice

  • Referral to specialty treatment is indicated for patients with severe or complicated substance use problems, high risk of substance use problems,or comorbidities, when these are beyond your training level or the resources of your practice. Referral is also indicated when brief interventions (and brief treatment) have not been effective.
  • Cognitive behavior therapy and group-based approaches are the most commonly used with the best evidence for effectiveness in treatment of substance use disorders.
  • Comorbid mental health problems and substance use disorders is called "dual diagnosis" and increases the need for specialty referral. These patients need to have both their mental health and substance use disorders treated. Whether to refer patients with psychosocial issues for medical management (psychiatry) and/or counseling (psychologists, substance abuse counselor, licensed clinical social workers, etc.) should be considered.

Apply quality improvement

  • Make a referral in every instance that it is indicated, because patients do not tend to self-refer. If you do not make the referral, treatment is not likely to happen.
  • Follow up through supportive phone calls and a scheduled appointment will likely increase the effectiveness of brief interventions and referrals.
  • Send the patient's medical history and a letter of referral before the patient's first visit to the specialist.
Importance of Ongoing Communication with the Specialist
Doctor counseling patient

Primary care providers can act as the patient's medical home, coordinating care with specialists, as well as being a source for referrals. While it may take additional time, the benefits are worth the effort (for example, in terms of reduced problem drug interactions and fewer redundant treatment processes) (IOM, 2006).

After Referral
Steps to take after referral include:
  • Become familiar with the addiction treatment plan.
  • Establish an agreement between members of the treatment team that describes the care each will provide.
    • Develop common goals and a shared understanding of roles.
    • Prevent role confusion and conflict through clear, proactive communication.
    • Be clear about: Who is my patient? Who is our patient? Who is your patient?
  • Develop a protocol for maintaining effective, ongoing, two-way communication.
  • Check to make sure that follow-up messages are received from the specialist.
  • Share the decision making. Disagreements on treatment need to be identified and openly discussed with a goal of consensus (IOM, 2006:212).
  • Continually share information with other healthcare providers throughout the patient's treatment.
  • Conduct a periodic review of the co-management process.
After Treatment

It is difficult for substance abuse treatment providers to keep in touch with their clients after discharge, so primary care providers play an important role as part of a patient's aftercare program.

Primary care can support continued recovery by continuing to provide screening, assessment, support, and encouragement as well as referrals for return to treatment as needed.

VA/DOD Practice Pocket Guidelines

The VA/Department of Defense has created a comprehensive guideline for treating substance use disorders. Excellent clinician pocket guides that summarize much of what has been presented here on this subject and many further details are available free-of-charge in the Provider Summary, Screening and Treatment, and Stabilization pocket guides available in the Related Resources section on this page.

View ReferencesHide References
Institute of Medicine (IOM). Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Institute of Medicine. Board on Healthcare Services. 2006. Available at: Accessed on: 2010-07-06.

Here is an example of dialogue that could take place during a follow-up contact.

(over the phone) Hi, Mrs. Capello, this is Anna from Dr. Green's office. We wanted to check on how your treatment at <Substance Use Disorder Treatment Center> is going.

Thanks for calling. I had an interview and intake appointment. I start treatment next Tuesday.

That's great! You've made an important first step! We encourage you to keep going and give the full treatment program a chance to work. I'll see you at your next appointment <specify date>.

All right. Thanks for calling.

View ReferencesHide References
O'Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground.. Arch Intern Med. 2011; 171(1): 56-65. Available at: Accessed on: 2013-10-24.
Early Follow-Up

It is important to make sure the patient followed through on a referral. Some patients require a lot of support and multiple motivating interventions before they will get the treatment you recommend.

The treating facility is likely to provide a reminder phone call and possibly call if the patient misses an appointment. The referring provider's office can also support the patient by calling to ask whether they kept the referral appointment and how it went.

Many patients get discouraged after learning a treatment will not work for them, or if their insurance was not accepted. They may not even think to call and ask you for another referral. Also, be sure to ask about their progress at the next appointment. If the patient is not interested in another referral, use further brief interventions to encourage them to get treatment.

View a sample communication from the specialist back to the referring provider:

Example of a letter from a specialist back to the referring providerFebruary 1, 2011

Adam South, MD
North Primary Clinic
1004 West Highway
Eastville, NC 27514

Dear Dr. South:

You referred Kelly Burch to this facility last week. She has signed releases of information so that you may receive clinical updates. Ms. Burch completed a Comprehensive Substance Abuse Assessment on January 31, 2011, and started therapy groups the very next evening.

The results of the substance use evaluation were consistent with your impressions. Ms. Burch provided a comprehensive alcohol/drug and psychosocial history during the clinical interview. She also was given a standardized alcohol assessment instrument. The findings indicated that she does meet the clinical criteria for alcohol dependence. Her drinking has become problematic, as you recognized. She meets the admission criteria to be placed in an Intensive Outpatient Treatment Program, based upon the American Society of Addiction Medicine Patient Placement Criteria.

Ms. Burch was willing to accept the treatment recommendations based upon the findings of the comprehensive evaluation and at your encouragement. To date, she has attended 4 outpatient therapy groups and has remained totally abstinent for 8 days. Ms. Burch met with her addiction therapist and established a treatment plan (see enclosed). She appears motivated for treatment at this time and states that she will attempt to comply with the treatment program's service contract (see enclosed).

As is customary in this program, monthly progress reports regarding Ms. Burch will be sent to you. These reports will contain updates on Ms. Burch's progress in treatment, urine drug results, and attendance. If you need additional or more immediate information, please do not hesitate to ask.


George Jones,
Certified Addiction Specialist

Later Follow-Up

Re-assess patients who previously participated in treatment:

  1. Review patient history and past treatment approaches, attempts, and outcome
  2. Screen for current substance use problems
  3. Test for drugs in bodily fluids and other laboratory tests when appropriate
  4. Discuss relapse using non-judgmental attitude
View ReferencesHide References
O'Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground.. Arch Intern Med. 2011; 171(1): 56-65. Available at: Accessed on: 2013-10-24.


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