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New Strategies for Substance Use Assessment: 5 Reasons Why

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW

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“He used K2, cocaine, and heroin. He says he takes his medications, but he keeps going in and out of the hospital. And the team does not know what to do,” lamented Maryann, the clinician on the HOPE ACT team, discussing the case with Rodis, the team consultant. Maryann was alluding to Raj, who often meets with her, but she wonders whether he really wants to get better.

Substance Use Disorder is a chronic condition that requires long-term treatment, and any progress made often waxes and wanes. Like Maryann, you may similarly work with patients and clients affected by Substance Use Disorder, and you may no longer know what to do. Part of the answer starts with an effective and comprehensive substance use assessment.

Below are five reasons why it is crucial for us to learn new strategies for substance use assessment:

Patient and Client Perspective

Sometimes we fail to ask our patients and clients about their current use or history of substance use. When we do, we either ask it as a “matter of fact” or stop after the first one or two questions, or we simply do not know what the next questions should be. “Maryann, what is Raj’s pattern of use, and what has been the evolution of his use,” asked Rodis. “I must confess, I never even thought about asking him,” replied Maryann. “With the new strategies for completing a comprehensive substance use assessment, you will know the right questions to ask, how to ask them, and you will be able to formulate a plan to provide better care for Raj.  Let’s get to work.”  Rodis and Maryann began developing a plan for substance use assessment.

“The team does not know what to do…frankly, he is not a favorite, and we have been making much more of an effort with Ron, who does not use drugs, than with him.”  Maryann was referring to Raj, who, we know, uses K2, cocaine, and heroin. It is a human tendency, ethical, and acceptable to like Ron better than Raj. It becomes questionable, however, when we start neglecting Raj and not stop to think or reflect on why,” whispered Rodis.

“I never thought about it that way before, but, now, I think I hate Raj. It has been exhausting working with him; he does not seem to want to get better. I hate feeling like I have been taken advantage of; any efforts I have made to try helping him feel wasted. More than any other client, he reminds me of other things I don’t do for myself, in my personal life, because I have no energy when I leave work.” With teary eyes, Maryann articulated these words to Rodis, who had invited her to reflect upon what Raj’s behavior might be evoking in her and how she could use it to better empathize with him, to become more objective and to use the evoked feeling for the benefit of the relationship, for Raj’s care.

Clinician and Advocate and Staff Perspective

We have been practicing healthcare in a silo. This is true when it comes to integrating mental health and primary care, and even more so when it comes to integrating substance use treatment and mental health care. “I must confess, I never even thought about asking him,” Maryann replied, “I realize that we, as a team, have been treating Raj just like we treat Ron, who does not have a Substance Use Disorder. We have not really been addressing Raj’s substance use needs; we simply have been expecting him to stop.” Raj belongs to the HOPE ACT team, where about 80% of the patients and clients have an active substance use disorder, some more severe than others and all at different stages of change.

“It is not just about motivation; it is more complicated than that. We have been waiting for Raj to just get motivated, without really doing our part. I got it now, and I am going to lead the team towards this goal and truly be an advocate for Raj.” This was Maryann’s promise to Rodis.  She will be able to keep this promise through the implementation of new strategies for substance use assessment that she has started to learn with him. Knowledge and awareness are empowering tools; they provide us with different perspectives and force us to challenge ourselves. As a result, we can become better advocates for our patients or clients.

As Maryann stated, it is not just about motivation, it is more complicated than that. Many of us prefer the simplistic view that substance use is a problem of character.  Some firmly believe, “You just need to have more will power, and you will be motivated to stop.”

With the new strategies for completing a comprehensive substance use assessment, you will feel armed and empowered with the right tools, to educate the various stakeholders, fight against the stigma of Substance Use Disorder, and help others understand that having a loved one admitted to the Medical Intensive Care Unit (MICU) for a diabetic coma, for failing to take his or her medications or follow the recommended behavioral modifications, is not much different than having a patient or client relapse on cocaine, after promising to remain “clean.”

“He used K2, cocaine, and heroin. He says he takes his medications, but he keeps going in and out of the hospital.  And the team does not know what to do,” lamented Maryann, the clinician on the HOPE ACT team, discussing the case with Rodis, the team consultant. Maryann was alluding to Raj, who often meets with her, but she wonders whether he really wants to get better. After a lengthy discussion with Rodis, Maryann admitted that she did not know the right questions to ask someone like Raj, affected by a Substance Use Disorder. She realized that Raj was evoking personal emotions and that her team was failing to integrate substance use treatment and mental health care. Rodis introduced Maryann to some new strategies for completing a comprehensive substance use assessment, and she vowed to start advocating for Raj, to start educating herself and colleagues to continue fighting against the stigma of substance use disorders.

You may be failing to provide the right care to your patients and clients with substance use disorder. You may also be using your counter transference and biases to their detriment, unknowingly and unintentionally. Learning the new strategies for completing a comprehensive substance use assessment will help you avoid falling into this trap. It will also help you promote and practice integrated substance use treatment and mental health care; improve your awareness and advocacy skills on behalf of your patients and clients with substance use disorders; and become a passionate educator to help decrease stigma against substance use disorders.

References:

  1. Volkow ND, Koob GF, McLellan AT (January 2016). “Neurobiologic Advances from the Brain Disease Model of Addiction”. N. Engl. J. Med. 374 (4): 363–371.

  2. Malenka RC, Nestler EJ, Hyman SE (2009). “Chapter 15: Reinforcement and Addictive Disorders”. In Sydor A, Brown RY. Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 364–375.

  3. White HR, Widom CS (May 2008). “Three potential mediators of the effects of child abuse and neglect on adulthood substance use among women”. J Stud Alcohol Drugs. 69(3): 337–47.

  4. Ohannessian, C.M., Hasselbrock, V.M. (1999). Predictors of substance abuse and affective diagnosis: Does having a family history of alcoholism make a difference?

  5. Pilgrim CC, Schulenberg JE, O’Malley PM, Bachman JG, Johnston LD (March 2006). “Mediators and moderators of parental involvement on substance use: A national study of adolescents”. Prev Sci. 7 (1): 75–89.

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