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: http://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGPocketCardStabilizationFinal.pdf 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: http://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGPocketcardScreeningandTreatmentRevised12716.pdf 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: http://www.nap.edu/read/10027/chapter/1 Accessed on: 2015-07-15.

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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.
Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single question alcohol screening test. J Gen Intern Med. 2009; 25(4): 375. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695521/ Accessed on: 2017-03-09.

Recommend that patients stay within low risk limits for their health: The Dietary Guidelines Advisory Committee (USDA, 2015), recommended:

  • Women: No more than 1 drink per day on average
  • Men: No more than 2 drinks per day on average

Recommend limits for drinking in a single day (NIAAA, 2015):

  • Women: No more than 3 drinks in any single day
  • Men: No more than 4 drinks in any single day

Note that higher limits in the accompanying NIAAA guideline were focused on achieving low risk for developing alcohol use disorder. However, low risk is not no risk. The lower limits in the Dietary Guidelines recommendation from the USDA considered wider health ramifications and the latest evidence on risk for developing alcohol use disorder.

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NIAAA. Alcohol Facts and Statistics. NIAAA. 2015. Available at: https://pubs.niaaa.nih.gov/publications/AlcoholFacts&Stats/AlcoholFacts&Stats.pdf Accessed on: 2015-04-29.
USDA. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. . 2015. Available at: https://health.gov/dietaryguidelines/2015-scientific-report/pdfs/scientific-report-of-the-2015-dietary-guidelines-advisory-committee.pdf Accessed on: 2015-11-21.

Once you complete the "Buprenorphine Training: Waiver Training for NPs & PAs [Part 1: 8 of 24 hours]" or "SBIRT and Motivational Interviewing: Waiver Training for NPs & PAs [Part 2a: 5 of 24 hours]" and "Opioids, Pain, and Risk Reduction: Waiver Training for NPs & PAs [Part 2b: 11 of 24 hours]", your information is recorded in our records. If you have an NP or PA degree, your information is sent to SAMHSA at the beginning of the next work week.

Things to Note:

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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: http://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGPocketCardStabilizationFinal.pdf 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: http://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGPocketcardScreeningandTreatmentRevised12716.pdf Accessed on: 2017-02-21.

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