# 8 Back to Basics: A Stigma-Free History

August 25, 2022 | By Carolyn Chan

with Dr. Jeanette Tetrault

Challenge stigmatizing terms and level up your patient-centered language! Learn how to create an inviting environment to discuss substance use and substance use disorders (SUDs), how our word choices directly affect patient care and a three-step approach to taking a comprehensive SUD History. Let’s RIP-TEAR it up with our expert, Dr. Jeanette Tetrault from Yale University (@jtetrault17).

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Credits

• Producer: Kenneth Morford
• Show Notes: Hannah Daneshvar MD MPH and Natalie Stahl MD, PMH
• Cover Art, Infographics: Natalie Stahl, MD MPH
• Hosts: Carolyn Chan, MD and Kenneth Morford, MD
• Reviewer: Katherine Mullins, MD
• Showrunner: Carolyn Chan, MD
• Technical Production: Castos Production
• Guest: Dr. Jeanette Tetrault

Production Partner: ACAAM

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio – 1:00
• Guest one-liner – 3:47
• Case from Kashlak – 6:09
• Definition of Addiction – 6:30
• Preferred Terminology – 10:30
• Evidence that supports the use of non-stigmatizing language – 17:40
• Person First Language – 20:30
• Framework for discussing substance use (3 steps) – 21:30
• The Spectrum of Alcohol Use – 29:00
• Evaluation using RIP-TEAR – 31:30
• Discussing a diagnosis of a substance use disorder  with a patient – 40:00
• Terms to Avoid – 44:26
• Take Home Points – 45:00

Just Say No To Stigma Pearls

1. Substance use disorders (SUDs), colloquially known as “addictions,” are chronic diseases. We can normalize treating them as such among our peers and patients by diagnosing and managing them as we would any other chronic disease. 
2. Our terminology impacts our patients and our environments; while patients may use colloquial terms with regard to their substance use, healthcare professionals should reflect accurate language that minimizes stigma. 
3. Person-first language is critical in all aspects of healthcare, but especially for patients with SUDs. We are not defined by what we put into our bodies but rather by who we are and how we interact with the world.
4. Remember, a patient doesn’t fail treatment, but treatment may fail a patient.  Treatment may not help a patient to achieve the desired outcome at one time in one setting, but this does not mean that the treatment is no longer an option for that patient.  
5. RIP-TEAR is a mnemonic that can be used to take a substance use history. 
6. The DSM-V criteria are used to diagnose SUDs. Remember that substance use alone is NOT a diagnosis of an SUD. 

Understanding Addiction: The Biopsychosocial Model

Addiction is a treatable, chronic medical disease involving complex interactions among brain

circuits, genetics, the environment, and an individual’s life experiences. People with

addiction use substances or engage in behaviors that become compulsive and often continue

despite harmful consequences (ASAM).

Central to this definition is the concept that addiction is preventable, treatable, and complex. Addiction is not a personal choice or moral failing. Furthermore, we must consider the social, environmental, legal, and political structures that contribute to our patient’s experiences. 

Addiction as a Chronic Disease

Strategies for the prevention and treatment of SUDs generally have similar rates of success compared to those of other chronic diseases. Clinicians should keep this in mind in both our practice and our conversations with patients and their families.

Relate the experience of addiction to something that a patient and their families can understand – such as managing a different chronic disease (e.g., diabetes, depression). Analogies can provide a useful, personal frame of reference and empower patient engagement in conversations about their health. As with any chronic illness, to be an effective clinician for your patient, it’s vital that you understand what it’s like for them to live with addiction and how it affects their day-to-day life.

Perpetuation of Stigma through Language

This episode explores how the words we use to describe patients and their substance use behaviors can substantially impact our patients’ health care experiences. The language we use also affects how our colleagues perceive patients. Two studies that focused on the effect of language in chart notes and the clinical environment (Kelly 2010, Kennedy-Hendricks 2022) found that critical terms describing patients and their substance use behaviors influenced clinician treatment choices and general approaches to care. By simply using accurate and nonjudgmental terms, we can break down the stigma in our discussions of substance use and SUDs.

We should use person-first language as a tool to decrease stigma. Traditionally clinicians described patients in relation to their disease (“a diabetic”); person-first language challenges this convention by placing a patient’s humanity first and foremost. We owe each patient recognition as a person WITH an illness; in the context of substance use, person-first language defines us not by what we put into our bodies but rather by who we are and how we interact with the world. An example of person-first language would be to say a “patient with cocaine use disorder” as opposed to a “cocaine addict.”

Another way to avoid perpetuating stigma in communication with patients and colleagues (including in documentation) is to avoid non-medical, judgmental, and/or stigmatizing terminology related to substance use.

Words Matter: Terms to Avoid & What To Use Instead

Substance Abuse: While previously an accepted term per the DSM IV, as of the DSM V (published in 2013), “substance abuse” is no longer in use and has been replaced with “substance use disorder.” Similarly, “alcohol abuse” or “drug abuse” are outdated and stigmatizing terms that often perpetuate bias and fail to provide substantive clinical information.

Instead, use “substance use” or name specific substance(s) the patient uses. If the patient has a SUD, use the appropriate diagnosis.

Addict/alcoholic/junkie: While our patients may use terms like these in describing themselves or others, as healthcare professionals, we should reflect accurate terminology, challenge stigmatizing language norms, and use person-first language.  Instead, use “patient with [specific substance] use disorder” and, as able or appropriate, specify the severity of SUD and whether or not it is in remission.

“Clean”/”Dirty” urines: Often, we hear the results of urine toxicology screens framed as “dirty urine” or “clean urine.” Where else in medicine do we refer to a condition or a test as “dirty”? 

Instead, we should refer to results that are “negative/positive for [specific substance]”

“Failing” Treatment: A patient doesn’t “fail treatment” although treatments often fail our patients. A patient who experiences a negative outcome with a treatment in one setting could still be eligible for that treatment in the future.

In the meantime, note whether or not the patient achieved a stated goal (i.e. abstinence, decreased substance use, continued use) during or after the treatment episode.

“Medication Assisted Treatment” (MAT): Even compared to other stigmatized illnesses (i.e. mental health conditions, HIV), in SUD treatment is often stigmatized as much as the disorder itself. When we use “medication-assisted treatment” to describe buprenorphine or methadone, we lose the perspective that medication doesn’t ASSIST treatment – it IS the standard for evidence-based treatment (Friedmann 2012).

Instead, use “medications for opioid use disorder? [MOUD] or  “medications for alcohol use disorder” [MAUD], etc.

Alcoholic Cirrhosis: Several diagnoses invoke terms like “alcoholic” in their very names – such as alcoholic hepatitis and alcoholic cirrhosis. It is therefore very easy for us to use these terms, but we again want to model appropriate and accurate terminology to everyone. 

ICD10 codes make this one difficult, but when possible use “alcohol-related” hepatitis or cirrhosis. 

Taking a History

Creating an open environment for our patients:

Talking about substance use and SUDs can be difficult. You can create a welcoming environment for these discussions with open-ended questions, a non-judgmental approach, and an engaged and inquisitive mindset. Questions such as “Can you tell me more about your story and how you use substances?” can go a long way in giving you information that not only helps contextually but diagnostically.  It’s important for patients to feel they are in a non-punitive space – you can verbally or visually signal this with statements such as “at our clinic, we take care of our patients, no matter what.” Meet people where they are by asking permission to discuss sensitive subjects, and by giving them space to teach you (conversations about substance use should be bidirectional between patient and clinician). Ultimately, your goal is to learn enough information to offer patients treatment options and allow them to make informed decisions about their care.

Context is also critically important in these discussions. If substance use comes up incidentally while discussing other medical issues, or as part of a routine screening, patients may need time before they feel ready to explore the topic with you. It’s important to consider that if someone is uncomfortable, whether emotionally or physically (i.e. in active withdrawal, in pain, or fatigued) the conversation can be touched on lightly in the context of getting permission to come back and discuss the subject more later. In those situations, patient comfort should be prioritized. 

3- Step Approach to a Substance Use History

Dr. Tetrault breaks down her history-taking approach into three simple steps for all patient visits: 

1) Screening, 2) Assessing, and 3) Evaluating patients. 

• Screen: Institute evidence-based screens into your clinical practice. Consider the use of single-question screeners that can be integrated into electronic medical records (e.g, single item screen for alcohol use; single question screen for drug use; USPTF substance use screening recommendations)
• Assess: If you have a patient who screens positive,  assess their use. Get a sense of what substance(s) they use, and whether they meet DSMV criteria for a SUD Rather than memorize the list of 11 diagnostic criteria, instead consider how substance use impacts a patient’s life in three ways: physiologic manifestations (cravings, tolerance, withdrawal), behavior (do they use a substance despite ongoing negative health consequences or life consequences?), and loss of control when using a substance (do they use more than intended, have they been unable to cut down despite desire to do so).
• Evaluation: For patients with substance use and/or SUD, consider using the RIP-TEAR mnemonic to gather more detailed information about their substance use history to complete your evaluation and prepare for treatment planning. 

RISK

Identifying imminent risks to a patient’s health is vital. Imminent concerns might include factors such as safety of drug supply (e.g. overdose risk), or whether a patient is in a vulnerable state (e.g., at risk for withdrawal). These risks need to be immediately addressed to ensure patient safety.

INITIATION

Once imminent risks are identified and addressed, we can start asking more global questions. When did the patient first begin using substances – of any kind – and under what circumstances? This information frames our perspective by giving us a sense of the length of time and intensity with which substances have been a part of the individual’s life. Understanding what has driven a patient’s substance use  (e.g. pursuit of an effective anxiolytic?) can influence how we speak with our patients and help us in treatment planning.

PATTERN

It’s important to understand patterns in our patients’ substance use (e.g. route of use, quantity, frequency, temporal patterns) to deduce triggers, evaluate the potential for withdrawal symptoms, and identify potential avenues for harm reduction.

TREATMENT EPISODES

What are the patient’s past experiences with treatment? If a patient tells you treatment was unsuccessful (“Gee, I used disulfiram for alcohol use in the past, and it didn’t work for me”) – finding out “What didn’t work? What was the issue?” is key; sometimes a struggle or concern was correlated (but not directly related to) a given treatment (i.e. patient identified disulfiram as causing anxiety, when anxiety was more likely due to alcohol cessation). Understanding past treatment episodes will help us frame current treatment options in the context of the patient’s hopes and concerns. 

EFFECTS (Positive and Negative)

Understanding both the negative/undesired effects of substance use or SUD and the positive experiences/benefits of substance use is critical. Summarizing and reflecting back what a patient has shared about their relationship with a substance (including an understanding of how the substance has helped them) has a major impact on the patient’s experience of the interview and can help the clinician and patient elicit the patient’s goals.

ABSTINENCE

While abstinence is not every patient’s goal (or the only outcome we look for in treatment), inquiring about any past periods of abstinence can help us understand what periods of stability look like for a patient or how they felt during periods of non-use.

RETURN TO USE

What risks or triggers do we need to consider that may cause our patients to return to use or unsafe or unstable situations? For example, anniversaries of loved ones’ deaths can be very difficult for individuals with SUD. Exploring and understanding these areas can help health care providers make a treatment plan that includes appropriate tools and supports.

Take Home Points:

1. Provide compassionate patient care by using accurate and respectful language in written and oral communications, both with patients themselves and with other health professionals.
2. Ask open-ended questions and use reflective language to collect a more informed and informative history.
3. Let the criteria guide you (either the eleven DSMV criteria or the three umbrella categories that comprise SUD) as you organize your history and guide the patient toward the creation of a patient-guided treatment plan. 
4. Use the RIP-TEAR mnemonic to collect a comprehensive substance use history for each substance that a patient uses. 

Links

1. https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction
2. 2. Addiction Medicine Fellowships are great! Visit ACAAM to learn more.

Goal

Listeners will be able to perform a comprehensive substance use disorder assessment. 

Learning objectives

After listening to this episode, listeners will be able to perform a comprehensive substance use disorder assessment. 

1. Employ patient-centered, non-stigmatizing language when discussing the care of individuals with substance use and substance use disorders (SUDS). 
2. Describe a 3-step approach to assessing an individual for a SUD.
3. Diagnose a patient with a SUD using DSM-V criteria.
4. Apply the RIP-TEAR mnemonic to take a comprehensive substance use history.  

Disclosures

Dr. Jeanette Tetrault reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Daneshvar H, Tetrault J, Stahl N, Mullins K, Morford K, Chan, CA. “#8 Back to Basics: A Stigma-Free History with Dr. Jeanette Tetrault”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/addiction 8/25/2022