“Things have been feeling different with Raj. Communication is much more clear, as he has been talking more to us, and we feel we have been making a difference in his life.” Edward, also a clinician on the Hope ACT team, articulated these words to Rodis, the consultant, who has been meeting with Maryann regarding New Strategies for Substance Use Assessment. “Thank you for joining us, Ed; it is good to hear about the great work you have started with Raj. Let us give you a summary of what Maryann and I have been discussing so far.”
In the two previous articles entitled, New Strategies for Substance Use Assessment: 5 Reasons Why and 5 Additional Reasons Why of New Strategies for Substance Use Assessment, I outlined a total of ten reasons why it is crucial to learn and implement the New Strategies for Substance Use Assessment. To set the tone and provide context, I have summarized these ten reasons.
The first five reasons are as follows:
- Better care for our patients and clients;
- Better use of our countertransference and biases for the benefits of our patients and clients;
- Promotion of integrated substance use treatment and mental health care;
- Improvement of our advocacy skills on behalf of patients and clients affected by substance use disorders; and
- Provide better education and the tools to decrease stigma against substance use disorders.
And the five additional reasons are:
- To enhance communication;
- To enhance clinical outcomes;
- To decrease waste in healthcare;
- To halt the cycle of fragmented care; and
- Educated expectations.
“Regarding everything you are learning, it is now time for the Hope ACT team to move to the next step of implementing the new strategies for conducting a substance use assessment.” Rodis updated Edward to the-same-page currency with Maryann and the rest of the team. Let us go on this journey together.
Below are five questions to ask during your next substance use assessment.
1. Pattern of use
Pattern of use varies depending on the individual and his or her environment, and asking about it provides us with several advantages. This should be framed as an open-ended question, to allow a deeper understanding of the intensity and severity of substance use, without making the patients and clients feel uncomfortable and without being too invasive, at the start of an assessment. This also allows the opportunity for the patients and clients to feel in control, as they talk about their pattern of use. Knowing the pattern of substance use also helps us design a tailored plan, something realistic and practical. Working with someone who primarily binge-uses will be different from working with someone who considers himself or herself a social user or a functioning user. Maryann had not thought of asking about pattern of use. After her meetings with Rodis, however, she has now incorporated this into her arsenal, especially in her work with Raj.
2.Triggers to use
For some, triggers relate to negative emotions; for others, they include exposure and other environmental factors, such as, certain places, paired behaviors, and the types of social networks, like friends. As the HOPE ACT team started to apply these new strategies in their work with Raj, they learned that, “I tend to use heroin when these flashbacks get to be too much. It becomes too painful, and I just need to numb myself,” explained Raj, with his head down and tears in his eyes. Asking your patients and clients about triggers can
- help them reflect and better understand what it usually takes to engage in substance use;
- identify what may need to be addressed to increase the likelihood of obtaining and maintaining sobriety; and
- aid in preventing relapse.
Sometimes your patients and clients may find it challenging to pin point some of the triggers, but you can better help them by your patience, prompting, and skills with the new strategies for conducting a substance use assessment.
3.Management of cravings
Managing cravings starts with self-awareness. Ask your patients and clients how much they are aware of their cravings. And follow with how have they been managing or responding to them. This is a powerful way to lay the groundwork for a solution-based approach to conducting a substance use assessment. “I used to call my ex-girlfriend right away, each time I felt like using. She is no longer around, and now I just give in to it.” Learning about how your patients and clients manage their cravings provide you information about their coping skills, some of their strengths and support systems, and it alerts you to any additional tools that can be used as part of a successful plan. Raj no longer had his girlfriend to call. It was a loss, which, later on, the team discovered had escalated his use. It was also a sign that a strong and loving relationship may be one of the promoting factors for Raj to achieve sobriety and help prevent relapse.
4.Explanatory model of use
The way that our patients and clients explain why they use may be a powerful strategy for us to join with them, reach them where they are at, and establish rapport. It also sends the message that we strive to understand them better; we are interested in a collaborative process, and we value their expertise about their life and body. Patients and clients come to us with all types of preconceived thoughts and beliefs. They have been stigmatized and subjected to discrimination and many are victims of trauma. They come to us, sometimes unwillingly, and other times, willingly, giving us the benefit of the doubt. In the former case, they often hold deep-seated beliefs they will be judged and seen as “just another addict who will never get better,” and they will be told exactly what needs to be done, regardless of what they think might work.
Asking your patients and clients for their own explanatory model of substance use provides a type of disarming, helping them to lower their guard to demonstrate trust. This process is intended to gather their input from the very beginning, in order to collaboratively help move things forward with them. “I’ve gone through a lot. I saw my mom being raped and killed in front of me, and I could not save her. I have always hated myself for that and when those pictures come back in my head, I just cannot take it.” Whether the explanatory model for your patient or client aligns with yours or not, you will have something to work with, something that he or she agrees to. And that alone is a powerful step towards change.
The answers to the previous four questions will often contain some hints for the response to the questions related to the escalating factors. In Raj’s case, his K2 use was recent. “I never thought I would touch K2. It is a bad and dirty drug and it makes you do crazy stuff. After my girlfriend left me, I thought there was no need to try anymore.I then started to use more cocaine, and when I didn’t have enough money for it, I started doing lot of K2,” explained Raj.
As you take your time and ask these questions of your patients and clients, several themes will emerge. In Raj’s case, for example, loss, relationship issues, guilt, and a poor sense of self have been some of the repeating messages. He said it using his own words and terms, something far more powerful than if you or I were to interject, regardless of how eloquent.
“Things have been feeling different with Raj. Communication is much more clear, as he has been talking more to us, and we feel we have been making a difference in his life.” Edward, also a clinician on the Hope ACT team, articulated these words to Rodis, the consultant, who has been meeting with Maryann regarding New Strategies for Substance Use Assessment. “Thank you for joining us, Ed; it is good to hear about the great work you have started to do with Raj. Let us give you a summary of what Maryann and I have been discussing so far.”
And so, it went, five questions to ask as part of your New Strategies for Substance Use Assessment. Next time you meet with your patient or client, ask about:
- Patterns of use;
- Triggers to use;
- Management of cravings;
- Explanatory model of use; and
- Escalating factors.
And you will be able to say like Maryann and Edward, “Things have been feeling different with Raj…we feel we have been making a difference in his life.” You also will avoid falling into the trap of unknowingly and unintentionally failing to provide the right care for your patients or clients with substance use disorder.
Please continue to share your experiences and these articles with your colleagues. I look forward to seeing you again through either our next article, or through our next seminar. Thank you for allowing me to be part of your noble journey, and until soon.
Your friend and colleague,
For more in this series of articles, check below!
Dr. Sidor is quadruple board certified in psychiatry, with board certification in General adult, Child and adolescent, Addiction, and Forensic, psychiatry. He also has additional training in public psychiatry, in several treatment modalities, in addition to his teaching, supervision, mentorship, and management, experience. Some of his passions are public speaking, leadership, business, and research, in addition to program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the past-Medical Director for CASES (Center for Alternative Sentencing and employment Services), and he speaks and writes fluently in six (4) languages—French, English, Spanish, Creole, and has intermediate proficiency in Portuguese and Italian.
- Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS).
- EMCDDA, A gender perspective on drug use and responding to drug problems, Lisbon, 2006.
- National Drug Intelligence Center, United States Department of Justice, National Drug Threat Assessment 2010, February 2010.
- National Institute on Drug Abuse, Monitoring the Future, Overview of Key Findings in 2009, Bethesda, Maryland, USA, 2010.
- Centre for Addiction and Mental Health, Ontario Student Drug Use and Health Survey, Drug use among Ontario students, 1977 – 2009, 2009.
- UNODC and CICAD, First Comparative Study on Drug Use and Associated Factors in the General Population aged 15-64, April 2008.
- EMCDDA, Statistical Bulletin 2009 and Hibell, et al, ESPAD Surveys 1995, 1999, 2003 and 2007.