Shared Decision Making

Shared decision-making, recommended for all patient care by the Institute of Medicine report, Crossing the Quality Chasm (2001), is especially important for patients with substance use disorder (VA/DoD, 2017). This should include deciding what treatment they obtain for their substance use disorder. Patients must have all information they need to make the decision in language they understand. Shared decision making also involves learning and respecting their priorities and involving them in setting goals.

Using a patient-centered approach, review outcomes of the patient's attempts to change their substance use previously including reasons they may have abandoned other treatments. Ask about their willingness to engage in treatment or a referral.

Engagement Strategies

Patients often express ambivalence or resistance to treatment at first and may continue to resist a referral (VA/DoD, 2015). Several principles are helpful in facilitating the patient being open to engaging in treatment:

  • Emphasize that treatment is effective, more effective than no treatment.
  • Consider previous treatment experience.
  • Motivational interviewing is often an effective approach for patients expressing the full range of readiness to engage in treatment. This includes an emphasis on:
    • Building self-efficacy that they can change
    • Develop a therapeutic alliance
    • Strengthen coping skills
    • Use reinforcement
    • Build social support
  • Emphasize that participation in treatment and community support are strong predictors of outcome.
  • Promote active participation in mutual help groups (e.g., Alcoholics Anonymous (AA), Narcotics Anonymous (NA))
  • Recommend coordinated treatment of substance use problems with interventions for biopsychosocial problems. (Consider patient priorities in this.)
  • Recommend the least restrictive setting possible for access, safety, and effectiveness.
  • Make efforts to re-engage patients who drop out of treatment.
  • Maintain use of Motivational Interviewing even if the patient is unwilling to engage in treatment, offering medical and psychiatric treatment as needed while looking for opportunities to facilitate further engagement of the patient in substance use treatment.
VA/DoD Guidelines

The VA/Department of Defense has created a comprehensive guideline for treating substance use disorders, from screening through treatment options. 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
Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders Stabilization Pocket Card . VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. 2015. Available at: Accessed on: 2017-02-21.
Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders Screening and Treatment Pocket Card. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. 2015. Available at: Accessed on: 2017-02-21.
Institute of Medicine (IOM). Crossing The Quality Chasm: A New Health System For The 21st Century. IOM. 2001. Available at: Accessed on: 2015-07-15.

Patients with moderate to severe substance use disorders or severe risk for them should be referred to a specialist or a treatment center for substance use disorders in the following cases:

Case Severity/Complexity

Criteria to use in determining case severity include the following:

  • A brief intervention is not adequate treatment, or has been tried and has not been sufficient.
  • Patients with severe substance use disorder. Additionally, patients that have moderate to severe alcohol use disorder, are using prescription drugs non-medically or illicit drugs, or have severe tobacco use disorder.
  • Patients have comorbid mental health disorders, low cognitive ability, or are on opioid therapy for chronic pain.
  • Patients have multiple or complicated medical conditions
  • Patients with a past history of substance use disorder
  • Patients with polysubstance use disorder
  • Pharmacological treatments for addiction are needed that are beyond the scope of your practice. This may include, for example, a patient who needs transfer from high-dose methadone maintenance or uses other high-dose opioids non-medically.
Other Patient Factors

Other factors that might require referral include the following patient factors:

  • Patients lack motivation or commitment needed for brief treatment to be effective.
  • Patient is non-compliant with your office policies or treatment protocol.
  • Patients request a referral.
Practice Factors

Factors relating to a provider's practice that may require referral include:

  • Having insufficient staff or other resources to provide brief treatment.
  • Patient's needs are beyond your expertise.
Practice Tip

Use Motivational Interviewing techniques to encourage the patient (or patient and parents, in the case of adolescents) to accept the referral.

Negative thoughts, sometimes called "stinking thinking" in drug and alcohol rehabilitation programs, and poor decision making lead to poor maintenance of abstinence and relapse in patients (Devine, et al., 2010). There are strategies for counselors to work with clients to recognize when they are having these thoughts and replace them with more productive thinking. This progress will also improve the decision making of the individual in dealing with cessation. The following steps illustrate how counseling session would help prevent a client from engaging in negative thoughts and poor decision making:

  1. Identify negative thinking: Have the client think of examples in the past when they have subjected themselves to negative thinking regarding abstinence from drug, tobacco, or alcohol use. Provide an example, if necessary, of common maladaptive thoughts.
  2. Do you ever think in ways that might be preventing you from succeeding? I know some people will say to themselves something like, "I know I'm going to mess this up."

  3. Identify Risky Decision Making: Ask the client for previous examples where they may have exposed themselves to others who use substances or certain triggers that can cause relapse.
  4. Do you ever unexpectedly find yourself tempted to exceed the limits you've set for yourself?

  5. Develop a Detailed Plan: It is important to give the client a detailed, specific plan to work with when they recognize a thought or decision that may impact their abstinence.
    1. Recognize the Risk: The first step is to recognize the risky thought or decision as they are happening.
    2. Challenge Thoughts and Decisions: Through the recognition and awareness, the patient can be guided by a counselor on how to replace these thoughts with more productive thinking and decisions.
  6. Practice and Role-Play: The client and counselor can practice these coping skills by filling out a worksheet of common negative thoughts and replace them with good thoughts. Another option is for the counselor and client to role-play certain risky situations for the client to gain experience and become more comfortable.

Earlier you mentioned being in a situation where you thought you could go to the bar but drink water or tea instead of alcohol, and this didn't work out as you planned it. How can you change your thought process in a similar situation in the future?

I will remind myself of what happened last time. The next time probably won't be any different and I should avoid it altogether.

Will this thought process help you to make a safer decision?

Yes. It will help me to avoid the situation entirely.

View ReferencesHide References
Devine EG, Brief DJ, Horton GE, LoCastro JS. Comprehensive Addiction Treatment: A cognitive-behavioral approach to treating substance use disorders. LULU Press. 2010; 4: . Available at: Accessed on: 2015-06-11.

In counseling and for clinicians who are able to have longer sessions with patients/clients*, discussing social pressure can benefit a patient's ability to maintain cessation and prevent relapse. The first step is to go through a typical week with the client to point out situations where they are likely to experience indirect social pressure (ie. being around people who are smoking) or direct social pressure (ie. being offered a cigarette) (Devine et al., 2010).

The following are ways the counselor can advise a client to avoid social pressure:

Do small things to change your environment Throw away any cigarettes you might have laying around at home
Anticipate and avoid social pressure Don't go to a restaurant with a bar
Escape feelings of temptations Have a plan to leave a party if you feel tempted to exceed your limit
Take a break from temptation Leave a situation with social pressure for only a short time to regroup your thoughts
Distract yourself Use something to distract yourself, such as chewing gum
Give yourself choices Bringing your own non-alcoholic drinks to a party or get together
Seek support Ask for encouragement from family and friends; Ask friends to avoid pressuring you
Bring support with you Having someone else who is trying not to smoke or drink will give you someone to relate with
Call somebody Call a friend or a support number to talk you through a situation

Coping skills can also be taught in counseling to turn down direct social pressure. One approach to learn coping skills is through role-play. The counselor and client will first discuss how to get through a conversation and then practice the refusal skills. The counselor and client can then summarize and reflect on how each of them felt after the role-play and complete further practice.

View ReferencesHide References
Devine EG, Brief DJ, Horton GE, LoCastro JS. Comprehensive Addiction Treatment: A cognitive-behavioral approach to treating substance use disorders. LULU Press. 2010; 4: . Available at: Accessed on: 2015-06-11.
When More Than Brief Intervention Is Needed

Patients who have a moderate to high risk for substance use problems, who have a moderate to severe substance use disorder, or who need but cannot obtain conventional treatment will likely need more intensive help than a brief intervention. Longer interventions, or those that take place over more than four clinical sessions, have been called Brief Treatment in contrast to Brief Intervention. A hospital setting or situation where a patient with a chronic condition requires regular clinic visits (e.g., pregnancy) may present the opportunity for brief treatment.

In some cases, a referral for treatment will not be possible due to a variety of reasons: rural location, transportation difficulties, or lack of patient interest. In these cases, spending a little extra time with the patient and utilizing at least one of the brief treatment tools presented can have a positive impact on patient outcomes. Counselors, who have more time to spend with patients, can review and utilize the following skills/techniques for brief treatment.

How Does Brief Treatment Differ From Brief Intervention?

The techniques used for brief treatment are the same as those already described for brief intervention, but applied more comprehensively. It includes more assessment, education, problem solving, coping skills, and finding support and is spread over multiple structured and focused clinical sessions. A brief treatment would cover more topics than a brief intervention and would be more likely to include medication if indicated. More intensive treatments may be more effective than brief interventions (Madras, 2009; Fiore et al., 2008).

Example of a Brief Treatment Schedule
  • Appointment 1: Raise awareness of the problem, clearly recommend stopping and explain benefits, and assess quantity/frequency of use and readiness to quit. This might be all that is accomplished in a single, brief intervention.
  • Appointment 2: Further assessment (including severity of dependence, personal consequences of use, and problem areas that would interfere with quitting) facilitate problem solving and raise awareness of benefits of quitting.
  • Appointment 3: Continue motivational interviewing as needed. If motivated, develop clear goals, assess commitment, and triage to the appropriate treatment setting. If quitting will be supervised in your clinic, schedule a date for quitting, develop a plan for quitting - identify changes needed in the environment, and find support
  • Appointment 4: Prescribe medication if indicated and schedule a follow-up appointment
  • Appointment 5: Follow-up in two weeks or less, assess medication effectiveness and side effects, and congratulate on any successes
  • For brief treatment to be effective, there has to be at least some commitment from the patient. A description of when referral is indicated instead of brief treatment is provided on the next page.

    View ReferencesHide References
    Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. Available at: Accessed on: 2013-09-26.
    Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites. Drug Alcohol Depend. 2009; 99: 280-295. Available at: Accessed on: 2011-03-24.
    Supplementing Treatment with Support Groups

    This discussion refers to support groups not run by licensed professionals and not qualifying as level I care, such as self-help groups run by peers. These groups can be an important way to gather additional social support, which is important in recovery.

    Self-help groups, such as Alcoholics Anonymous, are interventions that supplement substance use treatment and are often free, easily accessible, and usually open to anyone who wants to come. Some members of these groups use them as an alternative to professional substance use treatment, but they also are often used in addition to professional treatment.

    The no cost aspect is especially important in the wake of managed care (Laudet, 2000). Self-help groups can vary in philosophy (e.g. secular vs. spiritual), so patients may require referral to more than one group before finding an appropriate fit.

    The Range of Groups Available

    12-step groups. The most famous 12-step group is Alcoholics Anonymous although there are such groups for many other addictions. It is a common misconception that 12-step self-help groups are only suitable for patients with religious beliefs. 12-step programs have been shown to be effective regardless of an individual's religious background (Tonigan et al., 2002; Winzelberg & Humphreys, 1999).

    Other options. There are other networks of support groups available, such as Life Ring, Rational Recovery, Women's Recovery. These groups exist for alcohol, narcotics (broadly), cocaine, tobacco, prescription pills, and more. Many groups now also are available online.

    Recovery Support Services

    The Surgeon General's report, Facing Addiction in America, defines recovery support services as, "the collection of community services that can provide emotional and practical support for continuing remission as well as daily structure and rewarding alternatives to substance use" (USDHHS, 2016, Ch 5). Further, these services help individuals in recovery to acquire resources that will help them stay in recovery, such as better jobs, education, social opportunities, health, and general well-being. In addition to this support, ongoing monitoring and early re-introduction to treatment are often additional goals of these services. Recovery support services are found in various places including schools, health care systems, housing systems, and other community settings. Specific recovery support services include:

    • Recovery Coaching: Helps individuals being discharged from treatment to connect with community services and resources as well as to overcome barriers or problems that might interfere with continued recovery.
    • Recovery Housing: Provides a substance-free environment in which to recover as well as mutual support. Research on at least two such programs has shown improved long-term recovery rates
    • Recovery Management: Follows a protocol to monitor individuals during recovery long term. May involve in-person checkups or telephone case monitoring.
    • Recovery Community Centers: Often peer-led, recovery-focused. May provide any of the above recovery support services, 12-step meetings, education, social events, and access to resources that support recovery.

    (USDHHS, 2016)

    View ReferencesHide References
    Laudet AB. Substance abuse treatment providers' referral to self-help: Review and future empirical directions. Int J Self Help Self Care. 2000; 1(3): 213-225. Available at: Accessed on: 2013-10-24.
    Tonigan JS, Miller WR, Schermer C. Atheists, agnostics and Alcoholics Anonymous. Journal of Studies on Alcohol. 2002; 63: 534-541. Available at: Accessed on: 2015-06-17.
    USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: Accessed on: 2016-11-17.
    Winzelberg A, Humphreys K. Should patients' religiosity influence clinicians' referral to 12-step self-help groups? Evidence from a study of 3,018 male substance abuse patients. J Consult Clin Psychol. 1999; 67(5): 790-4. Available at: Accessed on: 2013-10-24.

    Mr. Martin, who was first introduced in the previous module, SBIRT: Brief Intervention and Other Treatments, and screened positively on the AUDIT for harmful or hazardous alcohol use and agreed to try to cut back on his drinking. He now returns for a 3-month followup.

    Patient: Mr. Mike Martin

    Age: 31 years old

    Scenario: Three months ago, he reported that he used to smoke occasionally and currently drinks alcohol, but does not use illicit drugs or misuse prescription drugs. He tested positively for hazardous or harmful alcohol use on the AUDIT (score=16/40. 8 or more is positive). It has been three months since the previous appointment.

    [After a greeting] Last time you were here, when we discussed your alcohol use, you agreed to cut back on your drinking. How is that going?

    Yes, in fact I cut back to no more than 2 drinks per day. Now I'm under that limit you mentioned last time, 14 drinks per week, right?

    Yes, that is great to hear! What benefits have you noticed?

    I never get hangovers now, so it's a lot easier to wake up in the morning. I guess I'm saving money too.

    I'm glad you are already experiencing benefits from cutting back. There are many more invisible benefits, too, in terms of improved health. I expect that cutting back even further would benefit you and your health even further. What concerns or problems do you have, such as temptations or pressure?

    It's getting hard for me to cut back any further. I just really look forward to a drink or two at the end of the day.

    You've had a great start cutting back on your own. Getting involved in social support, such as attendance in a 12-step plan, could really benefit you to decrease your use even further. There is a medication I can prescribe that would help, too.

    It is important to continue to be supportive after brief interventions or referral in order to help prevent relapse for someone who quit using a substance in the past few years. This might include:

    1. Congratulate them on any success.
    2. Offer strong encouragement to remain abstinent (or reduction of substance use, if appropriate).
    3. Ask open-ended questions regarding the following:
      • Benefits of quitting.
      • Describe their success (how long? resisted "temptations"?).
      • Any problems or concerns?
      • Remind them of the benefits of getting social support, such as attendance at 12-step meetings. For tobacco cessation, patients may also benefit from quit line counseling and should know about their local number or the national number 1-800-QUIT-NOW.
      • Medication check. Ask if medication for quitting is still being used. Effectiveness? Side effects? Adjust as needed. Any withdrawal if it is not being used?
      • Ask about negative mood or depression and address as needed.


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