3 steps for talking with patients about substance use disorder

When a patient with a substance use disorder comes in for a visit, talking to them about treating their addiction in a way that avoids the stigma that surrounds these disorders can be difficult. Learn how one physician approaches this conversation during her addiction consultations with patients.

Out in New Mexico, physicians and other medical professionals are putting in a lot of work toward ending the opioid overdose epidemic. Project ECHO (Extension for Community Healthcare Outcomes), a free-of-charge distance education model, connects primary care physicians with specialists to help them develop and share knowledge in the care of a variety of complex health conditions The program also has facilitated medication-assisted treatment (MAT) trainings for more than 375 physicians who are now buprenorphine-waivered.

But what about the simple yet critical act of beginning the conversation about treatment with a patient who has a substance use disorder?

As associate director of Project ECHO, Miriam Komaromy, MD, an internal medicine specialist and addiction consultant in New Mexico, spends the bulk of her clinical time conducting addiction consultations.

Primary care physicians refer patients to Dr. Komaromy so that she can talk with them, get to the heart of the disorder and figure out the best way to structure their treatment plans.

When a patient comes in for that first visit, Dr. Komaromy focuses on three things to minimize stigma and promote an effective dialogue:

• Let the patient tell their story. Start out broadly, asking open-ended questions to get the patient talking about their story—not their substance use disorder story, but rather their personal story. “I usually start by saying, ‘Tell me a little bit about yourself,” Dr. Komaromy said. “If they don’t immediately jump in talking about their substance use disorder, I say, ‘OK, now would you be comfortable telling me a little bit about your history of issues with substance use?’ The story really unfolds from there.” “People really want to tell their story, but they often feel constrained in a medical environment,” she said. “But if you allow them to [tell their story,] it can be the most efficient thing of all …. People want to be heard. You can get a lot of relevant information right up front.” “Certainly, by the time [a patient] is open to treatment, they’re not having a good time,” Dr. Komaromy said. “They’ve really exported to a phase of substance use disorder that’s miserable in trying to avoid withdrawal and struggling with something that feels like it’s got a stranglehold on them.”
• Get to the heart of the matter. Understanding the reason for a patient’s substance use is key to finding the treatment option most suitable for that patient. “They’re usually really hurting, and almost always they have some story of trauma that underlies it,” Dr. Komaromy said. “Part of what I try to do is not just help figure out how to address the substance use disorder right here and now, but also how do we start to address the underlying trauma or the possibility of post-traumatic stress disorder.”
• Convey respect. Stigma is a big issue in these conversations, and respect is a key ingredient to avoiding it. “People with substance use disorders, because of the stigma, are used to being treated badly,” Dr. Komaromy said. “It’s so important to convey respect. The message—on a really gut level—is that I’m just another human being like you, and I want to figure out how I can help.”

She recommends paying attention the following:

• Never conduct the interview while standing. Try to sit at the same level as the patient.
• Make eye contact.
• Say things that are encouraging, empathetic and simple during their story, “such as, ‘That sounds really difficult,’” she said. “It’s simple, but I think that plays a huge role in developing the start of a therapeutic relationship.”

Reducing the stigma of substance use disorders and enhancing access to treatment for those who have a disorder is one of the five things physicians can do to prevent opioid abuse, recommended by the AMA Task Force to Reduce Opioid Abuse, which physicians convened to help the nation move closer to the goal of ending the opioid epidemic. 

• Find out how a substance use researcher in San Francisco talks with his patients about substance use disorder.
• Learn how President Obama’s opioid initiatives align with the task force’s recommendations.
• Read a call to action for physicians to turn the tide of the opioid epidemic, and watch a video message from AMA President Steven J. Stack, MD.
• Find out what physicians are saying  about the new Centers for Disease Control and Prevention’s opioid guidelines.
• Learn what the AMA Task Force recommends for physicians to reduce stigma and increase use of MAT