Referring Professionals (Referring Patients as Part of Your Practice)

Doctors and other clinical professionals can be in an excellent position to recognize substance abuse in their patients and refer them to much needed treatment services. However, these medical professionals may sometimes feel like they don’t have the right tools to help them make these life-changing diagnoses and recommendations. In addition, it can be difficult to know exactly what types of facilities are more likely to help those patients, and what special services may be most appropriate.

In recent years, a number of tools have been developed to help physicians and other clinical staff members to identify potential substance abuse issues and provide intervention for their patients. In addition, knowing more about what type of assistance is more likely to help certain individuals can make it easier to recommend services that lead to lasting abstinence and a more positive outlook for long-term health. As described and championed by the Substance Abuse and Mental Health Services Administration (SAMHSA), these methods can be summarized as SBIRT, or:

• Screening to help determine if substance abuse is present and to what degree it is occurring
• Brief Intervention to inform the person about substance abuse risks and encourage the person to seek help
• Referral to Treatment for the individual to develop tools and skills for abstinence and recovery

Screening: How to Identify a Substance Abuse Issue in a Patient

When it comes to identifying a person who is struggling with substance abuse, doctors don’t always have it easy. With limited time to see people during an appointment, it can be challenging to get the information needed to determine whether or not a patient’s substance abuse might be a problem.

There are tools that can help with this. For example, the National Institute on Drug Abuse (NIDA) provides an online quick drug screening tool that can be used to ask screening questions and determine whether or not a person has a potential issue with:

• Alcohol
• Tobacco
• Prescription drugs
• Illicit drugs

Based on the responses received, the tool then provides information about the person’s potential risk factors and directs the clinician to further information on how to approach that person and, potentially, provide recommendations for further help. This can include continuing on to a more comprehensive series of questions to get more detail about the person’s substance use and abuse.

Strategies for Confronting the Patient

According to SAMHSA’s Treatment Improvement Protocols, once the screening is complete, the physician can determine the degree of intervention that is required, based on the suspected level of abuse. For patients with mild to moderate problems or who are at risk for substance abuse, a brief intervention can be performed. For those with more intense issues, an in-depth assessment and referral to treatment may be necessary.

In order for a patient to seek help, it is important for the person to achieve a level of readiness to change, as described in an article from Implementation Science. Before a person is ready to change, it is more difficult to get the commitment needed for treatment to be effective. The methods of confronting a patient are designed to assess and encourage readiness to change in the individual.

Brief Intervention

For those with only at-risk or mild to moderate abuse issues, a brief intervention gives the doctor a chance to explain the risks of beginning or continuing substance abuse. The doctor can express concerns about the level of substance use, and explain how cutting back on use can prevent some of the issues that might arise should drinking continue.

For example, this method is described by the National Institute on Alcohol Abuse and Alcoholism as consisting of between one and four brief counseling sessions that are used to help the individual start to moderate the use of alcohol. Through providing information, including handouts, the doctor can encourage the person to begin drinking less. This method usually requires little follow-up care.

A person with a high level of readiness to change will often respond quickly to the brief intervention. Therefore, the method usually requires little follow-up for these people. However, for those who are not ready to change, this method may not prove effective, even for at-risk, mild, or moderate users. In this case, moving on to a more in-depth assessment may be necessary.

In-Depth Assessment and Referral

When heavy substance use is apparent, or if brief interventions do not work in helping the patient with mild use issues to self-moderate, then the doctor can refer the person for a more in-depth assessment and intervention through a treatment facility. In this case, the doctor can express concern for the patient’s health based on substance abuse and provide a referral to a specific facility for the assessment.

In the case of a patient who refuses treatment or the referral, the doctor can return to the brief intervention model in an attempt to help the person achieve a level of readiness to change. As an alternative, as described in the Treatment Improvement Protocols model, the doctor can advise an intervention through family, if possible.

Once a person has indicated the readiness to change, the clinician can help the person determine the correct treatment option and facility. For those who are in crisis, intervention and immediate referral to a treatment facility may be necessary.

Helping a Patient Find Treatment Options

When the patient seems to be receptive to getting treatment, the doctor can use certain guidelines to help the patient find the options most suited to the patient’s needs. The patient placement criteria established by the American Society for Addiction Medicine (ASAM) provide guidelines for the physician to determine the patient’s treatment options, including level of care and treatment intensity and length. This is a reasoned, research-based model for providing levels of care based on the individual’s needs.

Recommending a Facility

Once the treatment needs and level of care have been assessed, the clinician can make a treatment recommendation. Specific facility information can be obtained through SAMHSA, local behavioral health departments, or, if necessary, law enforcement. However, there are some things to keep in mind before making a reference, such as:

• Treatment levels of care offered: Not all programs offer all levels of care.
• Special treatment needs: Certain patients may have additional needs during treatment, such as trauma-focused care, medical detox, or treatment for co-occurring disorders.
• Length of program: Studies show the longer the person is in treatment, the more likely it is that the person will have a positive outcome.
• Privacy: Some clients may have a greater need for privacy due to a high-level job or public presence.
• Aftercare: Programs that provide support after treatment is over can help people who are at higher risk of relapse.

These are just some of the considerations to take into account. However, one very important aspect to consider is whether or not the treatments used in the facility or program are shown through research to be more likely to promote recovery and abstinence.

The Principles of Effective Treatment described by NIDA demonstrate the elements that have been shown by research to create a higher chance of positive outcomes in treatment. Programs that incorporate these elements tend to have higher rates of recovery that can result in long-term abstinence from substance use after treatment is over.

Finding Research-Based Treatment Practices

Knowing which treatments are research-based and which aren’t can be difficult for a busy clinician. However, resources exist that can help with that determination, enabling the doctor to provide advice as needed:

• SAMHSA has a National Registry of Evidence-Based Programs and Practices that provides information on more than 350 different types of substance abuse and mental health interventions.
• SAMHSA also provides a web Guide to Evidence-Based Practices that enables a person to browse by topic, including prevention, treatment, and mental health disorder areas.

These are just some of the resources that can be used by clinicians and patients alike to research and understand the treatment practices that are shown to help those with substance use disorders. This information can be helpful in making sure that a facility with these practices is subsequently selected.

Meeting Special Needs

Sometimes a patient may have specific placement requirements based on the individual’s cultural, psychological, and other needs. The following are just some of the options to be aware of:

• All-male or all-female facilities to prevent distraction or intimidation by the opposite sex
• Facilities for women who are pregnant or who have children
• Facilities for minorities or specific cultural groups
• LGBTQ facilities
• Treatment for older people
• Treatment centers for people with disabilities
• Centers that specialize in treating people with co-occurring trauma issues
• Facilities that specialize in integrated treatment for other co-occurring mental health disorders

Many treatment centers can provide a range of these specialties. Understanding what local treatment centers have to offer can help doctors provide patients with the most relevant information to meet special needs.