Clinical Pearls For Treatment of Substance Use Disorders

By Dr. Sara Polley, M.D.

Establish your comfort level.

Each one of us are individuals with our own feelings and beliefs about substance use. We all have our own tolerance for risk in working with individuals with serious health concerns. It is important to reflect as a clinician about this, be honest with yourself, and transparent with your patients about your beliefs. I communicate my general style, philosophies, boundaries, and prescribing practices early and re-discuss as needed. One of the most beneficial things about intervention for any mental health condition is the patient-clinician relationship.  This type of communication helps establish a foundation of trust and openness. If I do not feel I am able to help a patient or family meet their goals in the way they would like, I discuss a plan for alternative care which may be more in line with what they are looking for. In these situations, I tell patients and parents they are always welcome to return to see me for additional consultation or discussion.

Involve family.

We know that one of the most effective treatments for all individuals with substance use disorders is family intervention. This is especially true for young people who are often in charge of decisions regarding their body but operate within their family’s expectations and structure. While it is not a requirement of the clinic, we encourage patients to include care givers in their treatment as we know this improves treatment outcomes. I offer sessions for caregivers where we can discuss boundaries and limit setting, the impact of substances on brain function and behavior, and communication. If a family would benefit from additional intervention, I refer to a qualified family therapist for continued treatment.

Discuss the specifics of confidentiality.

When working with young people, confidentiality is an important discussion to have at the start of treatment. Include the patient and any caregivers. In our dual diagnosis clinic, we discuss that diagnostic information and safety information will be discussed with families. We assure patients we do not share details of use patterns, friends, or “automatically” discuss a relapse or episode of use with a family. We do encourage children to sign a release of information for parent communication. I discuss that if I am concerned a patient’s use of substances is imminently unsafe, I will discuss with them first how to share information with a caregiver. We discuss examples such as driving under the influence, risk of overdose, or decisions made while intoxicated which create risk of death or serious injury.

Discuss Diagnostic Information.

The DSM 5 no longer makes a distinction between substance abuse and substance dependence. Instead, Substance Use Disorders are rated as mild, moderate or severe. I discuss this with families and patients after a comprehensive evaluation. I discuss other psychiatric diagnoses and the relationships between use of substances and difficulty with functioning which may mimic another disorder. This intervention alone can be valuable and assist a patient in becoming more deliberate about their choices. If a patient does not meet criteria for a substance use diagnosis but could benefit from intervention or psychoeducation, I discuss their pattern of “at risk use” and use this as a treatment target.

Consider use of medication or referral for medication evaluation.

Most patients with substance use disorders are not offered medication to help reduce or eliminate their use of substances. There are a number of medications available which are well tolerated and can be immensely helpful. In our clinic, I review options for treatment including therapy, school based intervention, community support groups, and medication. As a prescriber, it is important to become familiar with the options available and the strength of the evidence regarding their use. I share this information with families and assist them in making a decision that they feel comfortable with. We revisit this throughout their time in care. I often encounter discomfort with use of the medication Suboxone which is a treatment option for opiate use disorders. While it is not appropriate for all patients, this medication has been shown to reduce death from overdose, improve quality of life, and allow individuals to return to functioning. As a Suboxone prescriber, I feel very passionately that this medication can be an important tool in recovery and should be offered to those who would benefit.

Provide Narcan to your patients.

Naloxone (brand name Narcan, Evzio) is the medication which reverses the effects of opiates and heroin in the event on an overdose. I encourage a prescription be written for all families who are interested. While the patient may not be struggling with these particular substances, they may have a friend or family member who is at risk of overdose. This medication can be used to save a life and there are laws to protect individuals who are acting in good faith by giving this medication in the community. I review with my patients how to use nasal naloxone and discuss the signs and symptoms of opioid overdose.

Celebrate positive change.

I embrace a harm reduction approach which acknowledges a patient’s work anywhere on the continuum of change. This includes improved insight, safer decisions, reduced use or abstinence from substances. Holding this in mind allows me to focus on the goals of my patient and their family. I provide psychoeducation about the risks of use and the impact substances can have on other mental health diagnoses. I tell my patients they are in charge of choosing how they would like to use this information. I see myself as a consultant and partner in helping my patients and families live the life they find satisfying and healthy. While the only way to reduce risk of harm from substances completely is to abstain, not all patients will make this choice and that is okay.

The dual diagnosis clinic is open and accepting new outpatient referrals. We specialize in the care of adolescents and young adults with mental health concerns and substance use. We welcome individuals with and without a Rule 25 assessment. For those coming with an assessment and recommendations, our clinic is classified as offering early intervention (level of care 0.5) and outpatient care (level of care 1).

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