Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults

Date of current publication: May 30, 2024
Lead authors: Jennifer McNeely, MD, MS; Leah K. Hamilton, PhD; Susan D. Whitley, MD
Writing group: Timothy J. Wiegand, MD, FACMT, FAACT, DFASAM; Sharon L. Stancliff, MD; Brianna L. Norton, DO, MPH; Charles J. Gonzalez, MD; Christopher J. Hoffmann, MD, MPH, MSc, FACP
Committee: Substance Use Guidelines Committee
Date of original publication: October 21, 2020

This guideline on screening and risk assessment for substance use in adults (≥18 years old) was developed by the New York State Department of Health AIDS Institute (NYSDOH AI) for use by primary care clinicians and in other adult outpatient care settings in New York State to achieve the following goals:

• Increase the identification of unhealthy substance use among New York State residents and increase access to evidence-based interventions for appropriate patients. “Unhealthy substance use” refers to a spectrum of use that increases the risk of health consequences and ranges from hazardous or risky patterns of use to severe substance use disorder (SUD).
• Increase the number of clinicians in New York State who perform substance use screening and risk assessment as an integral part of primary care.
• Provide clinicians with guidance on selecting validated substance use screening and risk assessment tools and on providing or referring for evidence-based interventions.
• Promote a harm reduction approach to the identification and treatment of substance use and SUDs, which involves practical strategies and ideas aimed at reducing the negative consequences associated with substance use.

Rationale: In the United States, the use of tobacco, alcohol, and drugs (illicitly manufactured and nonmedical prescription) are among the top 10 leading causes of preventable death, accounting for more than 500,000 deaths per year White, et al. 2020; GBD 2018. Alcohol-related deaths have doubled in the past 2 decades; in 2019, there were more than 140,000 alcohol-related deaths in the United States CDC 2022. Surging rates of drug overdose deaths (often opioid-related) are a public health crisis across the country. In the United States, drug overdose contributed to 1 in 22 deaths in 2021, and there were more than 100,000 drug overdose deaths in the 12 months ending August 2023 CDC 2024; Gomes, et al. 2023.

Patient visits to healthcare settings are an opportunity for clinicians to identify substance use and related problems, offer timely interventions, and provide or link patients to treatment when indicated. Screening and treatment for tobacco use have been widely adopted as core clinical quality measures for primary care CMS 2013, but alcohol and drug use screening is not as widely performed, and use is substantially under-recognized Hallgren, et al. 2020; WHO 2016; Venkatesh and Davis 2000. Screening for alcohol use has been a recommended practice in adult primary care since 1996 Curry, et al. 2018. In a study of 13 states and the District of Columbia in 2017, 81.4% of patients reported being asked about any alcohol use by a healthcare professional; however, only 37.8% reported being asked about binge drinking behavior McKnight-Eily, et al. 2020.

Screening for substance use in primary care is generally well accepted by patients as a marker of quality care Simonetti, et al. 2015; Miller, et al. 2006. However, thoughtful implementation, with sensitivity to stigma and privacy concerns, is essential for patients and clinicians to be comfortable Bradley, et al. 2020; McNeely, et al. 2018.

The goals of screening for and assessing substance use risk in primary care vary by practice setting and resources and may include:

• Informing medical care: Substance use is an important aspect of medical history because it can significantly affect disease processes, response to treatment, and exposure to health risks. Knowledge of a patient’s substance use informs a clinician’s diagnosis of other medical and psychiatric conditions and alerts them to associated health risks (e.g., overdose, liver disease) and common comorbid conditions (e.g., depression). Similar to knowledge about a patient’s past medical history, family history, or social determinants of health, knowledge about a patient’s substance use helps clinicians formulate effective patient-centered treatment plans.
• Identifying the need for intervention: A second goal is to identify patients who would benefit from interventions to limit harms related to use and/or reduce their consumption (see guideline section Patient Engagement and Interventions) or patients for whom treatment may be appropriate (see guideline section Diagnosis of Substance Use Disorder). Evidence-based interventions are available, including brief interventions for moderate-risk alcohol use, pharmacotherapy for opioid and alcohol use disorders, and treatment for smoking cessation Patnode, et al. 2021; Patnode, et al. 2020; USPSTF(c) 2020; Curry, et al. 2018; Jonas, et al. 2014; Mattick, et al. 2014. Such treatments can be delivered effectively in a primary care setting, but they remain underused.
• Engaging patients: Another goal is opening the conversation and engaging patients in discussion about substance use. If approached sensitively, a nonjudgmental discussion of a patient’s substance use may reduce perceived stigma, improve the clinical relationship, and facilitate behavior change. Initiating such a discussion communicates to patients that substance use is a health issue that the clinician is concerned about and can offer help for.

Definitions of the terms used throughout this guideline are detailed below.

• Unhealthy substance use: Unhealthy substance use refers to a spectrum of use that increases the risk of health consequences and ranges from hazardous or risky patterns of use to severe substance use disorder. As defined in this guideline, unhealthy alcohol use is use that exceeds U.S. Department of Health and Human Services and Department of Agriculture 2015-2020 Dietary Guideline For illicitly manufactured drugs, less information is available about dosage and health risks of specific substances and preparations, and any use is considered potentially unhealthy. For prescription medications with potential for misuse, any nonmedical use (use of prescribed medication at increased dose or frequency or for reasons other than prescribed) or use of medications that were not prescribed is considered unhealthy.
• Screening: Screening entails asking patients brief questions (or a single question) about substance use and can quickly identify patients with potentially unhealthy substance use. Many of these patients will not have substance use-related clinical signs or symptoms Saitz(b), et al. 2014; Gordon, et al. 2013.
• Risk assessment: Risk assessment entails asking patients additional questions on the extent, duration, and pattern of substance use to determine the clinical significance and severity of use. Assessment tools determine the level of risk (i.e., low, moderate, or high) and thus the potential for negative consequences; see Box 1, below. As shown in Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions, risk level and other individual patient factors guide clinicians in recommending appropriate interventions and informing patients about the potential consequences of their substance use McNeely(a), et al. 2016; Saitz 2005.

In primary care settings, clinicians should screen all adult patients ≥18 years old for alcohol use. A large body of evidence indicates that screening tools can accurately identify unhealthy alcohol use (see Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults) and that brief counseling interventions can reduce alcohol use, improve health, and be cost-effective Patnode, et al. 2020; Kaner, et al. 2018; O'Connor, et al. 2018; O'Donnell, et al. 2014; McNeely, et al. 2008; Solberg, et al. 2008; Maciosek, et al. 2006. The National Committee on Quality Assurance adopted alcohol screening and brief intervention as a quality indicator in 2018 and incorporated it into the widely used Healthcare Effectiveness Data and Information Set performance measures.

In the absence of systematic screening, unhealthy alcohol use typically goes unidentified Hallgren, et al. 2022; McKnight-Eily, et al. 2020 or is identified by clinicians only when an individual has developed a severe alcohol use disorder or alcohol-related health problems, such as alcohol-related cirrhosis or pancreatitis.

Clinicians should screen all patients for all types of tobacco use, and when use is identified, provide counseling, assessment, and treatment Patnode, et al. 2021; USPSTF 2021. Every visit with a care provider allows for identifying a patient’s tobacco use and offering effective cessation interventions. Screening for tobacco use is often accomplished with 1 question: “Have you ever smoked cigarettes or used any other kind of tobacco?” Patients who answer “yes” should be asked about frequency and level of use in the past 30 days (e.g., number of cigarettes smoked per day) DHHS 2008. Despite concern about increasing rates of e-cigarette use, screening for electronic nicotine delivery systems is not currently a recommended practice Krist, et al. 2021; USPSTF 2021.

Based on clinical experience and expertise and federal recommendations USPSTF(b) 2020, this committee recommends that clinicians screen for drug use other than alcohol and tobacco in adult patients ≥18 years old who present for primary care. Screening should be performed in settings where treatment or counseling resources are available on-site or by referral and should identify a patient’s use of illicitly manufactured drugs and nonmedical use of prescription drugs that can be misused (e.g., opioids, benzodiazepines, and stimulants).

Evidence supports the accuracy of validated screening questionnaires in adults Patnode, et al. 2020 and the benefits of pharmacologic treatment for opioid use disorder (OUD), which can be delivered effectively in primary care settings Wartko, et al. 2023 and no longer requires a waiver for prescribing buprenorphine Stringfellow, et al. 2021. However, data on the effectiveness of drug screening plus brief intervention to reduce drug use and associated health consequences are currently limited, and this is an area of ongoing research. Randomized controlled clinical trials have generated mixed results regarding the efficacy of brief interventions in reducing drug use Sahker, et al. 2022; Patnode, et al. 2020; Gelberg, et al. 2015; Roy-Byrne, et al. 2014; Saitz(a), et al. 2014; Humeniuk, et al. 2012. Evidence supporting drug interventions delivered in primary care has primarily come from treatment-seeking populations, rather than patients identified only through screening Saitz 2020; USPSTF(a) 2020.

No currently published studies demonstrate harms directly associated with screening adult primary care patients for drug use, although the potential for harm does exist Saitz 2020. For some patients, especially those who are pregnant or planning to conceive, positive results from a drug screening test could pose social or legal consequences, such as required reporting and the potential for involvement of child protective services (see discussion below). It is essential to respect the sensitivity of any substance use information documented in patients’ health records and ensure that patients understand privacy protections for their health information.

Rationale for drug use screening: This committee’s rationale for recommending drug use screening in adult patients, even with the potential for harm in some specific circumstances, is based on the following:

• Stigma is a significant barrier to identifying and treating unhealthy drug use or substance use disorders (SUDs). The exclusion of routine screening for drug use may perpetuate the perception that discussion of drug use with healthcare providers is taboo. This is especially the case if alcohol and tobacco use are discussed openly but drug use is not mentioned. Routine, matter-of-fact, nonjudgmental screening for drug use may help reduce stigma by normalizing this discussion.
• The social history that clinicians currently perform typically includes questions about alcohol, tobacco, and drug use but may not collect this information in a systematic and clinically useful manner. It is important that clinicians screen for drug use consistently, in a nonbiased manner, and use standardized, evidence-based screening tools.
• Fatal and non-fatal opioid overdose deaths can be reduced through increased identification of unhealthy opioid use and, when indicated, effective treatment with medications for OUD Watts, et al. 2022; Wakeman, et al. 2020; Sordo, et al. 2017; Cousins, et al. 2016.
• Identifying and addressing unhealthy drug use, including drug use disorders, may positively affect other patient outcomes. For instance, identification of benzodiazepine use in a patient receiving opioids for chronic pain could inform overdose prevention counseling, opioid prescribing, and provision of naloxone to reduce the patient’s overdose risk.
• Knowledge of a patient’s drug use is essential for accurate diagnosis and treatment. For example, in a patient who uses cocaine, chest pain could be the result of drug use rather than a blocked coronary artery, but without knowledge of the drug use, the clinician will not have the information necessary to perform the appropriate diagnostic workup. In addition, knowledge of drug use may be essential for an accurate diagnosis of psychiatric disorders, and knowledge of injection drug use can help guide screening for infections.

Drug use screening in individuals who are pregnant or planning to conceive: Because there are potential legal and social consequences of a positive drug use screening result in individuals who are pregnant or planning to conceive, this committee urges caution when performing drug use screening. It is essential to engage patients in shared and informed decision-making before screening is performed. Fully informed consent includes clear discussion and confirmed patient understanding of the benefits, potential harms, and consequences of screening. For patients who are pregnant or planning to conceive, the informed consent discussion should include:

• Description of drug screening processes and procedures
• Potential benefits of drug screening for the patient
• Discussion of how results are interpreted and likely next steps if the screening result is positive
• Confirmation of confidentiality of the patient’s medical information
• Discussion of the risk of being reported to child protective services
• Discussion of the patient’s ability to refuse drug screening without repercussions, except in cases in which screening is mandated by an employer or by the court
• Psychosocial support and counseling about the potential harms of drugs and treatment options for SUD, if patients decline to be screened for other drugs

Screening is recommended for patients who use medications that have adverse interactions with alcohol or drugs. Iatrogenic harm is possible if a patient’s substance use is not identified, including adverse effects resulting from drug-medication interactions, overdose from combining prescribed medications with illicitly manufactured drugs, and withdrawal syndromes when a patient’s drug use is undisclosed and they are unable to use, such as during hospitalization Lindsey, et al. 2012; CDC 2007; Antoniou and Tseng 2002. Patients taking prescription opioids or benzodiazepines should be screened for use of alcohol and for illicitly manufactured or nonmedical use of other sedating drugs (including other opioids or benzodiazepines) that can increase the risk of overdose. Patients taking any controlled substances should be assessed for co-occurring substance use that may increase the probability of engaging in risky use of prescribed medications or of having or developing an SUD.

Clinicians should be aware of potential interactions between alcohol or drugs and medications, such as antiretroviral, pain management, or neurologic medications (e.g., gabapentin and pregabalin) Gomes, et al. 2017; Lyndon, et al. 2017; Lindsey, et al. 2012; Bruce, et al. 2008; Saitz 2005; Antoniou and Tseng 2002.

When counseling patients who use substances about drug-medication interactions, clinicians should be clear about the safety of their prescribed medications and be certain to encourage adherence to all critical medications, such as antiretroviral treatment Kalichman, et al. 2015.

See the following resources for checking drug-drug interactions:

• Drugs.com > Drug Interactions Checker
• University of Liverpool HEP Drug Interactions
• University of Liverpool HIV Drug Interactions

Clinicians should also perform substance use screening in patients who have symptoms or other medical conditions that could be caused or exacerbated by substance use, such as chest pain, liver disease, or mood disorders NIAAA 2024; Ries, et al. 2018; Kim, et al. 2017; Edelman and Fiellin 2016; Mertens, et al. 2005; Lock and Kaner 2004.

Successful substance use screening relies on accurate patient self-report. Although urine toxicology, measures of blood alcohol level, or other laboratory testing may detect the presence of substances used very recently (typically hours or ≤4 days after the last use), these tests are not appropriate for identifying unhealthy use, which may be intermittent and occur over time Bosker and Huestis 2009; Cone and Huestis 2007; Verstraete 2004. Laboratory screening tests for alcohol and drugs do not provide information about the severity or consequences of use and thus provide less information than questionnaires.

No reliable biomarker with sufficient sensitivity and specificity identifies the range of drinking behaviors that constitute unhealthy alcohol use Afshar, et al. 2017; Jarvis, et al. 2017; Jatlow, et al. 2014; Stewart, et al. 2014; Verstraete 2004; Neumann and Spies 2003. For drug use, urine, saliva, and blood testing are not recommended as replacements for questionnaire-based screening because laboratory tests have a brief window of detection (typically 1 to 4 days) Bosker and Huestis 2009; Cone and Huestis 2007; Verstraete 2004. Although hair testing has a more extended detection period, the cost and lack of reliability for detecting occasional drug use decrease its utility in primary care Verstraete 2004.

An optimal screening instrument will quickly and accurately identify individuals with the full spectrum of unhealthy use, fit into the existing clinical workflow, and have flexible administration options (i.e., self- or interviewer-administered). To facilitate patient reports of substance use, the language used in any screening tool should be clear and nonjudgmental. Drug screening should capture nonmedical prescription drug use and illicitly manufactured drug use. Table 1, above, lists recommended substance use screening tools.

The briefest approach to screening may be to use the Single-Item Screening Questions (SISQ) for alcohol or drug use (SISQ-Alc and SISQ-Drug). SISQ tools are validated for interviewer administration or patient administration and have good sensitivity and specificity. A positive response on SISQ tools identifies unhealthy use in the past year but does not indicate the level of risk. Both the Substance Use Brief Screen (SUBS) tool and the first section of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS-1) tool elicit information about use of tobacco, alcohol, illicitly manufactured drugs, and nonmedical prescription drugs through a single 4-item instrument. Like the SISQ-Alc and SISQ-Drug, the SUBS and TAPS-1 tools screen for any use in the past year, and a positive response indicates unhealthy use but does not identify level of risk. In states such as New York where cannabis is legal, asking about its use separately from that of illicitly manufactured drugs or nonmedical use of prescribed drugs may be preferable, and the Single-Item Screen-Cannabis, a validated single-item screening tool, is now available for this purpose Matson, et al. 2022; Sayre, et al. 2020.

Clinicians should use validated tools to perform substance use assessments in individual patients who have any of the characteristics discussed below. The purpose of assessment is to identify the level of risk (low, moderate, or high) posed by a patient’s substance use to guide clinical decisions about intervention, treatment, and follow-up (see Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions). Clinicians experienced in assessing and treating SUD may elect to use the Diagnostic and Statistical Manual of Mental Disorders-5-TR criteria as the initial assessment tool.

Positive substance use screening test: Given current levels of substance use in the general population and the negative effects of unhealthy substance use, any positive screening test result should prompt an efficient and accurate risk assessment McNeely(a), et al. 2015; McNeely(c), et al. 2015.

Known history of SUD or overdose: Polysubstance use is common in people with SUD Ellis, et al. 2023; Karamouzian, et al. 2022; Lin, et al. 2021; John, et al. 2018; Falk, et al. 2006. For patients with a history of SUD, identification of all substances used, including tobacco, and assessment of the associated levels of risk are indicated for early intervention and clinical decision-making. SUDs are chronic conditions, and even patients with long periods of abstinence remain vulnerable to resuming previous patterns of use McLellan, et al. 2000. Patients with a history of SUD may reduce or stop use of one substance but develop unhealthy use of a different substance (e.g., alcohol) Lin, et al. 2021; Callaghan, et al. 2018; Wang, et al. 2017; Falk, et al. 2006; Earleywine and Newcomb 1997. Overdose is frequently the result of polysubstance use, and use of fentanyl and stimulants (methamphetamine, cocaine) is driving unprecedented rates of overdose death Ciccarone 2021; Cicero, et al. 2020. The use of opioids in combination with alcohol or benzodiazepines also puts individuals at high risk of overdose Tori, et al. 2020. In patients with a history of nonfatal overdose, it is critically important to conduct an assessment and identify all of the substances being used; the results will guide education and treatment to reduce the risk of another overdose.

The level of risk of associated with substance use in individuals who are planning to become pregnant should guide clinician counseling, particularly in light of the risk of fetal alcohol spectrum disorder that occurs early in pregnancy May, et al. 2018; Moyer 2013; Stade, et al. 2009; Floyd, et al. 2008; Floyd, et al. 2006; DHHS 2005; CDC 2003. In addition, it is reasonable to perform a substance use assessment in patients with chronic diseases who have difficulty following through with treatment recommendations or are not responding as expected to treatment of their medical condition Garin, et al. 2017; Daskalopoulou, et al. 2014.

Substance use assessment tools are designed to collect information on the quantity, frequency, and duration of substance use and to indicate a risk level (see Table 2, below).

Many individuals with unhealthy alcohol use or other substance use regularly interact with the healthcare system, and primary care providers are optimally positioned to offer prevention, risk reduction, and treatment interventions. Routine screening and annual rescreening provide structure and opportunity to identify at-risk individuals, monitor for significant changes, and revisit identified concerns.

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework provides a comprehensive approach to the delivery of early intervention and treatment services for patients with unhealthy substance use of various degrees of severity. The key elements include:

• Screening/risk assessment to quickly identify at-risk individuals
• Brief intervention focused on increasing awareness and motivation toward behavioral change
• Referral to treatment to facilitate access to care

For additional guidance on implementation and reimbursement based on this framework, see Substance Abuse and Mental Health Services Administration (SAMHSA): Screening, Brief Intervention, and Referral to Treatment (SBIRT) and Box 2: Implementing Substance Use Screening in Primary Care Settings.

A positive substance use screening result should trigger further risk assessment, including a detailed history and understanding of individual risk factors; see guideline section Risk Assessment. Assessment tools determine the level of risk (low-, moderate-, and high-risk use) and thus the potential for negative consequences and appropriate interventions. Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions outlines the sequence of steps for the clinician.

When administering a risk assessment tool or during patient evaluation after a self-administered risk assessment, clinicians should remain alert to the patient’s perception of their substance use and readiness to change behaviors. Based on clinical experience, this interaction is an important opportunity to build rapport, dispel misconceptions, and engage patients in a therapeutic relationship. Understanding a patient’s readiness to change and identifying internal motivators for change provide important building blocks to shape the intervention strategy.

Motivational interviewing: Interventions tailored to match a patient’s level of risk, perception of their substance use, and readiness to change can promote engagement and increase the probability of progress toward goals VA/DoD 2015; SAMHSA 1997. The principals of motivational interviewing (MI) provide a framework for this approach, and all clinicians can develop the skills to educate, advise, offer treatment, or refer patients for appropriate interventions McLellan 2017; Edelman and Fiellin 2016. The core skills of MI, as defined by Miller and Rollnick, can be remembered with the acronym OARS, which stands for: open-ended questioning, affirming, reflective listening, and summarizing Miller and Rollnick 2013. For more information, see Resources box, below.

Trauma-informed care: Individuals with SUD have a high prevalence of childhood trauma Bartholow and Huffman 2023; Karsberg, et al. 2021; Zarse, et al. 2019, and substance use is a risk factor for repeated exposure to traumatic events Aronowitz and Meisel 2022; Simon, et al. 2020. Knowing that trauma contributes to challenges connecting to the healthcare system, clinicians and organizations with a trauma-informed approach can better overcome these barriers and improve outcomes. For more information on trauma-informed care, see the Resources box, below.

Positive reinforcement (for patients with low-risk substance use): For alcohol use, reinforce the benefits of staying below the U.S. Department of Health and Human Services and Department of Agriculture 2015-2020 Dietary Guidelines (1 drink or fewer per day for women and 2 drinks or fewer per day for men). Statements such as “The amount that you are drinking falls within a level that is considered safe for most healthy adults and is unlikely to have a negative impact on your health” and “In general, the less you drink, the better it is for your health” reinforce low-risk alcohol use. Be alert to pregnancy, older age (>65 years), and other health conditions that may warrant advice to drink less or not at all.

Brief advice (for patients with moderate- or high-risk substance use): Statements such as “As your healthcare provider, I am concerned about your alcohol (or substance) use and the potential impact on your health” and discussion of any related health effects (current or potential) should be integrated into the visit. This discussion can be supplemented by additional interventions as time and resources allow.

For individuals who use alcohol, clinicians can provide information on the recommended safe limits of use. Safe limits have not been established for older individuals or those with medical or psychiatric comorbidities. If a patient is hesitant, negotiate an individualized goal. Little information is available about the dose limits and associated health risks of cannabis and illicitly manufactured drugs.

Harm reduction strategies (for patients with moderate- or high-risk substance use): See the NYSDOH AI guideline Substance Use Harm Reduction in Medical Care for more information, including resources in New York State.

Overdose prevention strategies: Counsel patients to:

• Assume all illicitly manufactured opioids will contain fentanyl or other high-potency synthetic opioids and that stimulants and counterfeit pills may contain these agents.
• When possible, test drugs with fentanyl test strips or other drug-checking systems. Online sources include MATTERS (for New York State residents and programs, no charge), DanceSafe, and BTNX. Some NYS Authorized Syringe Exchange Sites may provide fentanyl test strips and other drug-checking systems.
• Try to avoid using drugs alone, and if they have to use alone, arrange for someone to check in or use phone- and web-based apps (e.g., Never Use Alone Inc. at 800-484-3731).
• When using any drug, start with a small amount.
• Carry naloxone (NLX), learn how to use it to reverse an opioid overdose, and encourage friends and contacts to do the same. The 4 mg NLX nasal spray formulation is available at pharmacies, at NYSDOH-Registered Opioid Overdose Prevention Programs (no charge), and through online resources such as NEXT Distro. NLX is covered by NYS Medicaid and most private insurers.

Brief interventions (for patients with moderate-risk substance use or high-risk substance use not diagnosed as a use disorder): A brief intervention is a time-limited, patient-centered strategy that focuses on increasing insight and awareness about substance use and motivation toward behavioral change. Brief interventions can range from 5 to 20 minutes in duration, vary in frequency, and include a variety of components. Common elements of a brief intervention include discussion of the risks and rewards of substance use as perceived by the patient and individualized feedback about the level of risk.

Using these techniques, clinicians can encourage “change talk” by amplifying statements about a patient’s desire, ability, and reasons for change Rollnick, et al. 2022. The amount of time spent in change talk is correlated with improved outcomes; the more a patient verbalizes their desire and reasons for change, the more likely it is to happen.

Robust evidence supports the efficacy of brief advice and other brief interventions in the primary care setting for reducing alcohol use among individuals with unhealthy use who do not meet the criteria for alcohol use disorder Curry, et al. 2018; Kaner, et al. 2018; O'Connor, et al. 2018. However, the optimal timing, dose, and order of interventions is unknown. A systematic review of the literature on brief alcohol intervention implementation in medical settings was unable to identify specific interventions that were clearly associated with improved outcomes Curry, et al. 2018. The most common component was the use of personalized feedback in which participants were shown how their alcohol use compared with that of others. Personalized feedback was often combined with MI or other strategies, such as drinking diaries, action plans, or alcohol use “prescriptions.”

Randomized controlled clinical trials have generated mixed results regarding the efficacy of brief interventions in reducing drug use Sahker, et al. 2022; Patnode, et al. 2020; Gelberg, et al. 2015; Roy-Byrne, et al. 2014; Saitz(a), et al. 2014; Humeniuk, et al. 2012. Evidence supporting drug use interventions delivered in primary care has primarily come from treatment-seeking populations rather than patients identified only through screening Saitz 2020; USPSTF(a) 2020. However, brief interventions are recommended by SAMHSA and have been implemented in many healthcare settings with no evidence of harm SAMHSA 2018.

In the absence of evidence to guide the choice of specific interventions, clinicians should engage in any strategies that are available and feasible. Clinician factors, including training and time restrictions, will guide strategy. Practice factors, including standard workflows, electronic health record decision support, and availability of integrated behavioral health specialists, can enhance the uptake and implementation of best practices Loughran, et al. 2021.

Because substance use behaviors can change over time, annual rescreening is recommended for individuals with low-risk substance use. For individuals with moderate- or high-risk substance use and those meeting criteria for an SUD, the frequency and type of follow-up will be individualized. As with other chronic diseases, the plan will vary based on the severity of the problem, presence of significant medical or psychiatric comorbidities, and the patient’s perception and goals.  When indicated, the plan should include referral for specialty services.

The diagnosis of an SUD and its severity is made by a clinical interview and based on DSM-5-TR diagnostic criteria (see Table 3, below) APA 2022. Diagnostic checklists incorporated into the health record can be helpful tools. Studies have confirmed that symptom checklists can reliably assess for alcohol use disorder criteria in patients who screen positive for high-risk drinking Hallgren, et al. 2022; a similar strategy may be useful for the diagnosis of other SUDs Matson, et al. 2023.

Individuals with a diagnosis of SUD should be offered pharmacologic and behavioral treatment as indicated and available (see Note [a], above). Conversations about treatment options should be guided by precepts outlined in the guideline section Patient Engagement. When referral to specialty addiction treatment is necessary, primary care providers can support patients in selecting treatment resources, navigating potential barriers, and checking in about progress while continuing to address medical needs.

Patients often present with concurrent SUDs and mental health disorders NIDA 2020. Symptoms of one can mimic the other, making it challenging to arrive at a definitive diagnosis SAMHSA 2019. Clinicians should consider a diagnosis of SUD before establishing a primary psychiatric diagnosis (e.g., alcohol-induced depressive disorder vs. major depressive disorder). Symptoms of intoxication, such as mood changes or perceptual disturbances, and symptoms of withdrawal, such as depression, anxiety, irritability, and insomnia, can also mimic psychiatric disorders and should be carefully assessed. Care providers should consult with a mental health specialist when symptoms are severe and/or when a clear diagnosis is difficult to establish.

Date of current publication: August 8, 2023
Lead authors: Jessica Rodrigues, MS; Jessica M. Atrio, MD, MSc; and Johanna L. Gribble, MA
Writing group: Steven M. Fine, MD, PhD; Rona M. Vail, MD; Samuel T. Merrick, MD; Asa E. Radix, MD, MPH, PhD; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD
Committee: Medical Care Criteria Committee
Date of original publication: August 8, 2023

Throughout its guidelines, the New York State Department of Health (NYSDOH) AIDS Institute (AI) Clinical Guidelines Program recommends “shared decision-making,” an individualized process central to patient-centered care. With shared decision-making, clinicians and patients engage in meaningful dialogue to arrive at an informed, collaborative decision about a patient’s health, care, and treatment planning. The approach to shared decision-making described here applies to recommendations included in all program guidelines. The included elements are drawn from a comprehensive review of multiple sources and similar  attempts to define shared decision-making, including the Institute of Medicine’s original description [Institute of Medicine 2001]. For more information, a variety of informative resources and suggested readings are included at the end of the discussion.

The benefits to patients that have been associated with a shared decision-making approach include:

• Decreased anxiety [Niburski, et al. 2020; Stalnikowicz and Brezis 2020]
• Increased trust in clinicians [Acree, et al. 2020; Groot, et al. 2020; Stalnikowicz and Brezis 2020]
• Improved engagement in preventive care [McNulty, et al. 2022; Scalia, et al. 2022; Bertakis and Azari 2011]
• Improved treatment adherence, clinical outcomes, and satisfaction with care [Crawford, et al. 2021; Bertakis and Azari 2011; Robinson, et al. 2008]
• Increased knowledge, confidence, empowerment, and self-efficacy [Chen, et al. 2021; Coronado-Vázquez, et al. 2020; Niburski, et al. 2020]

Collaborative care: Shared decision-making is an approach to healthcare delivery that respects a patient’s autonomy in responding to a clinician’s recommendations and facilitates dynamic, personalized, and collaborative care. Through this process, a clinician engages a patient in an open and respectful dialogue to elicit the patient’s knowledge, experience, healthcare goals, daily routine, lifestyle, support system, cultural and personal identity, and attitudes toward behavior, treatment, and risk. With this information and the clinician’s clinical expertise, the patient and clinician can collaborate to identify, evaluate, and choose from among available healthcare options [Coulter and Collins 2011]. This process emphasizes the importance of a patient’s values, preferences, needs, social context, and lived experience in evaluating the known benefits, risks, and limitations of a clinician’s recommendations for screening, prevention, treatment, and follow-up. As a result, shared decision-making also respects a patient’s autonomy, agency, and capacity in defining and managing their healthcare goals. Building a clinician-patient relationship rooted in shared decision-making can help clinicians engage in productive discussions with patients whose decisions may not align with optimal health outcomes. Fostering open and honest dialogue to understand a patient’s motivations while suspending judgment to reduce harm and explore alternatives is particularly vital when a patient chooses to engage in practices that may exacerbate or complicate health conditions [Halperin, et al. 2007].

Options: Implicit in the shared decision-making process is the recognition that the “right” healthcare decisions are those made by informed patients and clinicians working toward patient-centered and defined healthcare goals. When multiple options are available, shared decision-making encourages thoughtful discussion of the potential benefits and potential harms of all options, which may include doing nothing or waiting. This approach also acknowledges that efficacy may not be the most important factor in a patient’s preferences and choices [Sewell, et al. 2021].

Clinician awareness: The collaborative process of shared decision-making is enhanced by a clinician’s ability to demonstrate empathic interest in the patient, avoid stigmatizing language, employ cultural humility, recognize systemic barriers to equitable outcomes, and practice strategies of self-awareness and mitigation against implicit personal biases [Parish, et al. 2019].

Caveats: It is important for clinicians to recognize and be sensitive to the inherent power and influence they maintain throughout their interactions with patients. A clinician’s identity and community affiliations may influence their ability to navigate the shared decision-making process and develop a therapeutic alliance with the patient and may affect the treatment plan [KFF 2023; Greenwood, et al. 2020]. Furthermore, institutional policy and regional legislation, such as requirements for parental consent for gender-affirming care for transgender people or insurance coverage for sexual health care, may infringe upon a patient’s ability to access preventive- or treatment-related care [Sewell, et al. 2021].

Health equity: Adapting a shared decision-making approach that supports diverse populations is necessary to achieve more equitable and inclusive health outcomes [Castaneda-Guarderas, et al. 2016]. For instance, clinicians may need to incorporate cultural- and community-specific considerations into discussions with women, gender-diverse individuals, and young people concerning their sexual behaviors, fertility intentions, and pregnancy or lactation status. Shared decision-making offers an opportunity to build trust among marginalized and disenfranchised communities by validating their symptoms, values, and lived experience. Furthermore, it can allow for improved consistency in patient screening and assessment of prevention options and treatment plans, which can reduce the influence of social constructs and implicit bias [Castaneda-Guarderas, et al. 2016].

Clinician bias has been associated with health disparities and can have profoundly negative effects [FitzGerald and Hurst 2017; Hall, et al. 2015]. It is often challenging for clinicians to recognize and set aside personal biases and to address biases with peers and colleagues. Consciously or unconsciously, negative or stigmatizing assumptions are often made about patient characteristics, such as race, ethnicity, gender, sexual orientation, mental health, and substance use [Avery, et al. 2019; van Boekel, et al. 2013; Livingston, et al. 2012]. With its emphasis on eliciting patient information, a shared decision-making approach encourages clinicians to inquire about patients’ lived experiences rather than making assumptions and to recognize the influence of that experience in healthcare decision-making.

Stigma: Stigma may prevent individuals from seeking or receiving treatment and harm reduction services [Tsai, et al. 2019]. Among people with HIV, stigma and medical mistrust remain significant barriers to healthcare utilization, HIV diagnosis, and medication adherence and can affect disease outcomes [Turan, et al. 2017; Chambers, et al. 2015], and stigma among clinicians against people who use substances has been well-documented [Stone, et al. 2021; Tsai, et al. 2019; van Boekel, et al. 2013]. Sexual and reproductive health, including strategies to prevent HIV transmission, acquisition, and progression, may be subject to stigma, bias, social influence, and violence.

In addition to the references cited below, the following resources and suggested reading may be useful to clinicians.

References

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Avery JD, Taylor KE, Kast KA, et al. Attitudes toward individuals with mental illness and substance use disorders among resident physicians. Prim Care Companion CNS Disord 2019;21(1):18m02382. [PMID: 30620451]

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Castaneda-Guarderas A, Glassberg J, Grudzen CR, et al. Shared decision making with vulnerable populations in the emergency department. Acad Emerg Med 2016;23(12):1410-16. [PMID: 27860022]

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Coulter A, Collins A. Making shared decision-making a reality: no decision about me, without me. 2011. https://www.kingsfund.org.uk/sites/default/files/Making-shared-decision-making-a-reality-paper-Angela-Coulter-Alf-Collins-July-2011_0.pdf

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KFF. Key data on health and health care by race and ethnicity. 2023 Mar 15. https://www.kff.org/racial-equity-and-health-policy/report/key-data-on-health-and-health-care-by-race-and-ethnicity/ [accessed 2023 May 19]

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Niburski K, Guadagno E, Abbasgholizadeh-Rahimi S, et al. Shared decision making in surgery: a meta-analysis of existing literature. Patient 2020;13(6):667-81. [PMID: 32880820]

Parish SJ, Hahn SR, Goldstein SW, et al. The International Society for the Study of Women’s Sexual Health process of care for the identification of sexual concerns and problems in women. Mayo Clin Proc 2019;94(5):842-56. [PMID: 30954288]

Robinson JH, Callister LC, Berry JA, et al. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract 2008;20(12):600-607. [PMID: 19120591]

Scalia P, Durand MA, Elwyn G. Shared decision-making interventions: an overview and a meta-analysis of their impact on vaccine uptake. J Intern Med 2022;291(4):408-25. [PMID: 34700363]

Sewell WC, Solleveld P, Seidman D, et al. Patient-led decision-making for HIV preexposure prophylaxis. Curr HIV/AIDS Rep 2021;18(1):48-56. [PMID: 33417201]

Stalnikowicz R, Brezis M. Meaningful shared decision-making: complex process demanding cognitive and emotional skills. J Eval Clin Pract 2020;26(2):431-38. [PMID: 31989727]

Stone EM, Kennedy-Hendricks A, Barry CL, et al. The role of stigma in U.S. primary care physicians’ treatment of opioid use disorder. Drug Alcohol Depend 2021;221:108627. [PMID: 33621805]

Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019;16(11):e1002969. [PMID: 31770387]

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