Compassionate Support
Opioid dependence is one of the most strongly stigmatized forms of substance misuse in our culture today.

The strength of the shame associated with opioid misuse is one of the primary reasons patients are reluctant to disclose their drug use to physicians. Discomfort, fear, distrust, and hopelessness often further discourage patients from being open about their dependence.¹

This reluctance may be exacerbated in situations where patients were originally prescribed opioids for pain and now find that—even though the pain is gone—they feel compelled to continue using opioids.

The result is that people seeking help for opioid dependence often presume that others—including healthcare professionals—are passing judgment on them. In this context, ensuring that patients feel they are being addressed with empathy and respect is key to reinforcing their self-esteem and, in doing so, supporting their follow-through with treatment.²

For physicians, fear of offending their patients keeps many from asking about possible opioid misuse.

Many opioid-dependent patients want to stop, but feel powerless to do so. By screening for opioid misuse, physicians improve the likelihood that patients in need of treatment will receive the attention their disease merits. Information and methods for enhancing opioid-dependence screening in your practice are explored in more detail in the sections below.

Importance of Screening 
Encouraging Patients to Open Up
General Guidelines for Screening Questions
When to Screen

Importance of Screening
With any illness, screening is essential to interrupt the disease's progression.

Making a point to regularly screen all patients achieves 4 important ends:

1.	Increases the likelihood that opioid dependence is detected
2.	Decreases patients' feelings of being "singled out"
3.	Gives patients an opening to talk to you about dependence
4.	Increases patients' acceptance of dependence as a medical condition

People from all walks of life can become opioid dependent. Electing to screen only the patients with obvious symptoms or predisposing factors increases the risk that early-stage or atypical opioid use patterns will be overlooked.

In addition, the more screening experience you have, the more familiar you will become with the typical range of responses among patients, and the more comfortable you will feel about probing when the information departs from this norm.

Encouraging Patients to Open Up
Whether the disease is diabetes, cancer, or opioid dependence, an open dialogue between physician and patient is one of the most important factors contributing to successful treatment.

The techniques below are recommended to help physicians encourage and reinforce positive channels of communication with patients. These techniques may be particularly useful when treating opioid-dependent patients because of the heightened sensitivity to the perceived judgments of others that may be seen in this population:

Express empathy:
Demonstrating empathy for your patients' feelings conveys that you are listening and trying to understand their point of view. This, in turn, helps patients feel more comfortable about opening up and sharing details about themselves that may be relevant to their treatment.²

Avoid appearing judgmental:
Avoiding discussions or questions that your patients might interpret as passing judgment on them or their actions helps encourage more honest communication. Patients who sense that they are at risk of losing your approval may feel pressure to hold back or tailor their responses to fit what they believe you want to hear.²

Confirm the strict federal patient privacy laws:
Reassuring patients about the strict confidentiality of your conversations can often help them be more comfortable disclosing sensitive information, particularly if they are concerned about possible repercussions for themselves or their families.²

Project confidence and knowledge:
Patients are more likely to be honest with physicians they perceive as able to provide or facilitate the care those patients need.³ Projecting confidence and knowledge communicates that you are someone patients can rely on to help them.²

A summary of the attributes shown to facilitate effective patient communication^1-3:

• Able to establish a helping alliance
• Able to demonstrate reflective listening (eg, repeating what the patient has said to confirm that the patient is being understood)
• Empathetic, nonjudgmental
• Confident
• Professional
• Supportive
• Respectful
• Patient-centered
• Genuine
• Affirming

General Guidelines for Screening Questions
Most people initiate change when 2 basic conditions are met:

1.	They decide they want to change their behavior
2.	They feel strong enough to face the challenge of changing their behavior

Screening questions, therefore, are not designed to put patients on the spot or make them feel ashamed, as neither of these will encourage change. Instead, the goal is simply to learn as much as possible about the patient's condition.

Screening questions tend to be brief and focused on the patient's condition; they can be easily incorporated into a routine patient interview.

The following points reinforce the attributes shown to facilitate effective patient communication (mentioned above), and are useful when asking patients about substance use³:

• Keep questions direct and straightforward
• Avoid slang or "street" terms
• Use simple language rather than medical jargon
• Targeted, open-ended questions yield more information than yes/no questions (eg, "Tell me more about how drug X has affected your life" or "In the past, what factors seemed to help you stop using?")
• When there are other indications of drug use (eg, physical signs), assumptive questions can be effective (eg, "When was the last time you used drugs?" vs "Have you ever used drugs?")²

Sample questions
The following questions are based on the CAGE (Cut Down, Annoyed, Guilty, Eye-Opener) Questionnaire:

• Asking patients about how many physicians they are seeing and if they use multiple pharmacies can help identify prescription drug misuse
• One or more positive answers (in patients no longer requiring analgesia) to the following may indicate opioid dependence (according to the DSM-IV):
• Have you ever felt the need to cut down on your use of prescription opioid pain medications or heroin?
• Have you ever given up activities to use prescription opioid pain medications or heroin?
• Are you spending more time on activities to get prescription opioid pain medication or heroin?
• Have you ever used prescription opioid pain medication or heroin despite negative consequences?

In addition to the above questions, a number of generalized drug-screening tools are available, including:

• CAGE [PDF–Size: 12KB] (Cut Down, Annoyed, Guilty, Eye-Opener)
• DAST [PDF–Size: 17KB] (Drug Abuse Screening Test)

When to Screen
To facilitate early identification, intervention, and treatment of substance use problems, SAMHSA recommends routinely screening all patients for signs of substance abuse (SAMHSA, 1997).²

This recommendation includes regularly assessing patients' analgesic needs, as well as screening for possible opioid dependence when patients are being prescribed opioids for the treatment of pain.¹

Screening is also recommended in response to patient complaints about conditions that are attributable to opioid use, including²:

• Physical problems (eg, sleep disorders, cellulitis)
• Emotional problems (eg, anxiety, depression)
• Psychosocial or behavioral problems (eg, legal problems, social isolation, missed work or school)

If a patient's responses are not conclusive, but, perhaps, suggest a potential or early-stage problem, consider mentioning this just as you would for any other condition, for example:

"Your recent weight loss together with increasing feelings of anxiety could be your body's response to early stages of opioid dependence. Let's keep an eye on things, see if these issues resolve on their own, and if they don't, when you come back you and I can talk about office-based treatment options."

Being direct with patients about opioid dependence reinforces to them that this is a medical, not a moral, illness. This, in turn, signals to patients that it is okay to talk to you about their condition. Together with the option of private, office-based treatment, you may be offering patients a hope that was previously nonexistent.

Identifying Dependence