Once the patient is willing to change his or her problem substance use behavior, help them set realistic goals and agree on a plan to cut back on substance use or quit. Mention treatment options that will meet the patient's goals.

Treatment Plan Options

Many patients with less serious problems, such as at-risk drinkers, can be treated in primary care. Treatment options include:

  • Graduated reductions in substance use
  • A trial period of reduced substance use.
  • Total abstinence from the substance.
  • Medication assisted abstinence
    • Naltrexone may be prescribed to help reduce cravings in alcohol use disorder. For example, a brief intervention might include a 30-day trial and re-evaluation. An injectable, long-acting form is also sometimes used in opioid use disorder after detoxification. These uses of naltrexone are FDA approved.
    • Alcohol abstinence, after detoxification, may also be supported with disulfiram (Antabuse) (Jørgensen, 2011) and acamprosate (Campral®) (FDA, 2004a) which are approved by the FDA for this purpose. Gabapentin (Clemens & Vendruscolo, 2008; NIH, 2013) and topiramate (Johnson & Alt-Daoud, 2011) are also used in treating alcohol use disorder but this is an off-label use.
    • For opioid addiction, to prevent withdrawal symptoms, buprenorphine (can be started in the office of a waivered provider) or methadone (referral to a treatment clinic is needed) treatment is indicated.
Caution for Withdrawal from Some Substances

Patients with more advanced physical dependence on alcohol will need medical management of withdrawal, called detoxification, until the worst of the symptoms have subsided. Individuals who have engaged in heavy drinking for around a month or more who stop or even significantly reduce alcohol use without medical management can experience severe withdrawal that is potentially life-threatening (Stern et al., 2010). It is characterized by delirium tremens (tremors, fever, confusion, sweating, increased pulse, possible hallucinations) and possible seizures. Treatment typically includes benzodiazepines. Withdrawal from barbituates and benzodiazepines can be similarly severe. Patients with potential for severe withdrawal should be referred for management by addiction specialists.

View ReferencesHide References
Clemens KJ, Vendruscolo LF. Anxious to Drink: Gabapentin Normalizes GABAergic Transmission in the Central Amygdala and Reduces Symptoms of Ethanol Dependence. The Journal of Neuroscience. 2008; 28: 9087-9089. Available at: http://www.jneurosci.org/content/28/37/9087.long Accessed on: 2013-11-05.
Food and Drug Administration. Campral (acamprosate calcium) Label. FDA Website. July 30, 2004a. Available at: http://www.accessdata.fda.gov/Scripts/cder/DrugsatFDA/index.cfm Accessed on: 2010-10-29.
Johnson BA, Ait-Daoud N. Topiramate in the new generation of drugs: efficacy in the treatment of alcoholic patients. Curr Pharm Des. 2010; 16(19): 2103-2112. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20482511
Jørgensen CH. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcohol Clin Exp Res.. 2011; 35: 10. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21615426 Accessed on: 2013-11-05.
National Institutes of Health. NIH-funded study finds that gabapentin may treat alcohol dependence. National Institutes of Health. 2013. Available at: https://www.nih.gov/news-events/news-releases/nih-funded-study-finds-gabapentin-may-treat-alcohol-dependence Accessed on: 2013-11-05.
Stern TA, Gross AF, Stern TW, et al. Current approaches to the recognition and treatment of alcohol withdrawal and delirium tremens: "old wine in new bottles" or "new wine in old bottles". Primary Care Companion to The Journal of Clinical Psychiatry. 2010; 12(3): . Available at: http://www.psychiatrist.com/PCC/article/Pages/2010/v12n03/10r00991ecr.aspx Accessed on: 2017-03-16.

Use non-accusatory language when discussing substance use. Emphasize to your patients that they are not powerless in the situation and help them discover ways in which they do have power.Patients who believe they are being forcefully pushed toward change may resist - a signal to change your approach (Babor & Higgins-Biddle, 2001).

Example Dialogue

Here is an approach that is accusatory and therefore not:

 

(Example of accusatory tone) You're hurting your health with all your drinking and marijuana use. You've got to quit before it's too late.

 

You don't know anything about me! I don't think I have a problem. It's not affecting anything that I really care about in my life.

Here is an approach using non-accusatory language:

 

(Example with non-accusatory tone) At your level of use, both alcohol and marijuana could potentially affect your health in serious ways, and I'm concerned about that. For example, because you are of childbearing age and sexually active, drinking alcohol, any alcohol, could harm the development of your fetus if you became pregnant. So I recommend cutting down on the alcohol use and quitting marijuana altogether.

 

Yeah, well, I guess I knew that already...Like what would happen to the kid? And what other "serious ways" might I experience?

 

Benefits Of Quitting

Offer the patient specific advice about changing his or her behavior, including the benefits. Advise the patient to cut back or abstain, based upon the severity of the problem and the substance involved. Relate the advice directly to the patient's life and health as much as possible.

 

I'm concerned that you have been drinking more lately. You said that drinking helps you relax, but there are other ways to reduce stress that do not involve alcohol. What types of healthy stress management have worked for you? You'll have the added benefit of reducing your risk for heart disease, too.

Practice Tip

Female patients of childbearing age who may become pregnant should be advised that any drinking can result in fetal alcohol spectrum effects. Depending upon the timing, severity of the alcohol use, and genetic factors, a baby could be born with fetal alcohol syndrome. CDC reports the prevalence of any alcohol use in pregnant women to be 10.2%. The CDC also reports the prevalence of alcohol use in non-pregnant women of childbearing age to be 53.6%.

Though there have been prior guidelines about alcohol use in pregnancy, the American Academy of Pediatrics has found that there is no safe level or time period during pregnancy in which alcohol can be consumed (Williams et al., 2015). This means that all patients should be advised to abstain from alcohol throughout their pregnancy in order to prevent negative health effects.

View ReferencesHide References
Babor TF, Higgins-Biddle JC. Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care . World Health Organization. 2001. Available at: http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6b.pdf
Tan CH, Denny CH , Cheal NE , Sniezek JE, Kanny D. Alcohol Use and Binge Drinking Among Women of Childbearing Age-United States, 2011-2013. Centers for Disease Control and Prevention. 2015; 64(37): 1042-1046. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6128a4.htm Accessed on: 2015-09-25.
Williams JF, Smith VC, Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. American Academy of Pediatrics. 2015; 136: 5: 1395-1406. Available at: http://pediatrics.aappublications.org/content/early/2015/10/13/peds.2015-3113 Accessed on: 2015-10-22.
Discuss Personal Responsibility and Consequences

Next, discuss the patient's personal responsibility and consequences of their substance use, including health effects.

  • Relate the patient's substance use to specific health, medical, or social problems as much as possible.
  • Allow opportunities for questions, and summarizing, in order to assess the patient's understanding.
Example Dialogue

As your health care provider, I'm concerned about the amount you are drinking and how it's affecting your health. It may be contributing to your stomach problem. It's also increasing your risk of heart disease and other harmful medical conditions. Given your family history of heart disease, this is worrisome. You could reduce this risk by drinking within healthy limits.

It is important to help patients who have a substance use problem see that they have a choice and to help them connect their substance abuse to its consequences.

When you have 4 or more drinks in a night, what sorts of things happen that are not helpful in your life?

Show Interest In Their View of the Situation

Gauge the patient's feelings about his/her substance use to help guide the intervention. Patients who don't think they have a problem will be more resistant to treatment. Labeling it as a problem, before the patient comes to view it that way, may work against establishing agreement on the issue. You can simply describe the behavior instead.

Example Dialogue

Instead of saying:

 

How long have you had this problem?

 

 

It would be better to say:

 

How long have you been experiencing black outs when you drink?

 

 

Responding to the concerns from the patient's perspective will create rapport. For example:

 

The guys I hang with would wonder about me if I didn't smoke weed with them.

 

It sounds like any plans you come up with to stop using marijuana will have to keep your social situation in mind. 

 

 

Identify Risks

Use this opportunity to help patients develop awareness of what factors in their environment make it more difficult for them to quit and stay abstinent.

Present and Discuss Screening Results
Advise the patient that his or her screening answers about substance use indicate a health concern.
  • Point out your concerns by referring back to the patient's responses.
  • Verify that the patient was not confused by the questions and that they correctly completed questionnaires.
  • Give patients ample time to explain their positive answers.
  • Be clear that you are concerned, but not judging them.
Example Dialogue
I looked over your answers to the questionnaire about how much alcohol you drink. It suggests that the amount you drink in one sitting is sometimes beyond limits for safety and health. Can we talk about that?


Practice Tip

Establishing rapport with the patient will help him or her be open to engaging in a process that will move toward change. Adopting open, encouraging, non-authoritarian body language can help – for instance, sitting at the same level as the patient rather than sitting behind a desk or looking down at a seated patient.

What is Motivational Interviewing?

Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to stimulate personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion"
(Miller & Rollnick, 2012).


Communication skills adapted from this counseling technique can help motivate patients toward change. Motivational interviewing differs from an advice-giving approach by recognizing the expertise of the patient on his or her own motivations and guiding the patient to examine and resolve his/her ambivalence about the problem (Miller & Rollnick, 2012). These techniques have been shown to be effective in helping people overcome substance use disorders and other changes.

View ReferencesHide References
Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Applications of Motivational Interviewing Series. New York: Guilford Press.. 2012; 3rd edition: . Available at: https://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781609182274 Accessed on: 2014-07-08.

The basic steps in a brief intervention are:

  1. Confirm your concern with the patient's responses to screening questions.
  2. Ask patient's view of the situation, barriers to quitting, and risk factors for relapse.
  3. Discuss their personal responsibility for health effects and other consequences of substance use.
  4. Provide the patient with non-judgmental advice and discuss benefits of quitting.
  5. Mention treatment options when appropriate and gauge patient's reaction.
  6. Encourage and support the patient. Solicit commitment to a clear goal.
  7. Provide patient education and resources.
Practice Tips
Ideas for fitting brief interventions in a busy schedule:
  • Do as many brief interventions as you can in an appointment, but even one is better than none.
  • For patients who return regularly, a step can be completed at each appointment. Ask if they have given any thought to what you talked about last time.
  • Involve the whole clinic team. Many of these steps can be achieved by nursing or other staff.

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