Talking to Patients About Substance Use Disorders: Strategies for Primary Care Providers

Laura M. Cascella, MA, CPHRM

Substance use disorders (SUDs) are a common and growing public health and medical concern in the United States. According to the Substance Abuse and Mental Health Services Administration’s 2022 National Survey on Drug Use and Health, 48.7 million people aged 12 or older reported having a SUD in the past year — an increase of 8.4 million from the 2020 survey.¹ Unfortunately, only about a quarter of these individuals received treatment.²

Because substance misuse is common in society, it also is common in patients who present to primary care settings for any number of health reasons.³ As a result, primary care providers are in a unique position to help address this pervasive issue and guide patients to appropriate resources, including addiction specialists, behavioral health providers, social workers, physical therapists, community-based program staff, and peer support specialists.⁴

Despite this vantage point, primary care providers might find it difficult to talk to patients about substance use for various reasons. For example, they may feel like they do not have the knowledge or experience to help patients navigate SUDs. Although this concern is understandable, providers do not need to be experts on SUDs or addiction to broach the subject with patients.

Another reason primary care providers might hesitate to initiate these discussions is because of the sensitivity and stigma surrounding substance misuse and addiction. This hesitation is legitimate, but it also can perpetuate negative stereotypes and barriers to appropriate care and treatment.

To overcome these concerns and reluctance, providers can pull from strategies they use to have other difficult conversations with patients, such as delivering a less-than-favorable test result or disclosing an unanticipated outcome. Just like with these conversations, discussions about substance misuse can benefit from patient-centered communication strategies that prioritize physical, psychological, and emotional well-being.

Below are some guiding principles and strategies that can help primary care providers discuss SUDs with patients while promoting a safe environment:

• Ask permission to discuss substance use before directly questioning patients, and don’t pressure them to answer questions if they do not feel comfortable.
• Acknowledge that discussing substance use and its associated problems is difficult, but try to validate patients’ feelings and normalize the discussion.
• Be aware that trauma can increase the risk of substance misuse and SUDs, and consider the principles of a trauma-informed approach to care when talking with patients about these issues.
• Take care to avoid a punitive or judgmental tone when communicating with patients. Show empathy, and let them know that your primary focus is working together to support them and provide appropriate care.
• Be cognizant that words have power, and avoid stigmatizing language or word choices that patients might find derogatory. Use person-first language to describe patients rather than leading with their conditions (e.g., “patient with a substance use disorder” rather than “addict”).
• Explain the importance of addressing substance misuse and how it relates to their medical care and overall well-being.
• Reassure patients that your conversations are confidential, but also be transparent about situations that would require disclosure (e.g., risk of immediate overdose or threats of harm to self or others).
• Explain to patients that treatment and recovery are possible, but a one-size-fits-all approach does not exist. Discuss the importance of partnering with specialists and exploring the optimal path of recovery for each individual.
• Create an open dialogue and take time to listen to patients’ concerns without interrupting. Repeat key information to the patient to confirm your understanding of what they are saying, and ask them to do the same to ensure they comprehend what you’ve communicated. The teach-back technique is a good tool to help gauge comprehension.
• Maintain situational awareness of nonverbal communication (e.g., body language and facial expressions), and make sure it reinforces an engaged and empathetic stance.
• Treat patients with respect and dignity, and consider how culture may play a role in how they interpret and respond to situations involving substance use and information related to substance misuse and SUDs.
• Consider using a technique such as motivational interviewing to (a) better understand your patients’ goals and willingness to change, (b) foster open communication and reflective listening, and (c) develop a patient-centered approach to care.⁵

Compassionate communication that acknowledges patient’s beliefs, positions, and concerns is the cornerstone for facilitating productive conversations with patients about substance misuse and SUDs. Once effective communication and a partnership are established, primary care providers can begin to work with patients toward their treatment goals, refer them to appropriate specialists, and connect them with community resources.

For more helpful information related to this topic, see the following resources:

• Agency for Healthcare Research and Quality: Overview of Medications Used in the Treatment of Alcohol Use Disorder and Frequently Asked Questions
• American Family Physician: A Primary Care Approach to Substance Misuse
• Harvard Medical School: Integrating Addiction Treatment in Primary Care: Training Needs and Novel Approaches
• National Academies of Science, Engineering, and Medicine: Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings
• Substance Abuse and Mental Health Services Administration: Quick Guide for Clinicians Based on TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians
• U.S. Department of Health and Human Services: National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care

Endnotes

¹ Substance Abuse and Mental Health Services Administration. (2023). Highlights for the 2022 national survey on drug use and health. Retrieved from www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-main-highlights.pdf; Substance Abuse and Mental Health Services Administration. (2021). Highlights for the 2020 national survey on drug use and health. Retrieved from www.samhsa.gov/data/sites/default/files/2021-10/2020_NSDUH_Highlights.pdf

² Ibid.

³ Shapiro, B., Coffa, D., & McCance-Katz, E. F. (2013). A primary care approach to substance misuse. American Family Physician, 88(2), 113–121.

⁴ Centers for Disease Control and Prevention. (2022, March 2). Addiction medicine toolkit training modules: Care coordination in treatment of substance use disorders. Retrieved from www.cdc.gov/opioids/addiction-medicine/training/care-coordination-in-treatment-of-substance-use-disorders.html

⁵ Centers for Disease Control and Prevention. (2024, April 9 [last updated]). Addiction medicine toolkit. Retrieved from www.cdc.gov/overdose-prevention/hcp/toolkits/addiction-medicine.html; Substance Abuse and Mental Health Services Administration. (2001). Quick guide for clinicians based on TIP 24: A guide to substance abuse services for primary care clinicians (DHHS Publication No. [SMA] 01-3581). Retrieved from https://store.samhsa.gov/product/guide-substance-abuse-services-primary-care-clinicians/sma12-3581; National Academies of Sciences, Engineering, and Medicine. (2020). Caring for people with mental health and substance use disorders in primary care settings: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25927

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