Engaging Patients in Substance Use Disorder Treatment by Offering Support They Are Willing to Accept

What are the steps for engaging a young adult who clearly has a substance use disorder but seems to be in denial?

Drug use is common among young adults. According to the National Survey on Drug Use and Health, in 2022, more than 40% of young adults reported past-year use of illicit substances, including 14.4% who used an illicit substance other than cannabis (1). The prevalence of substance use disorders peaks between ages 18 and 25—with 27.8% of the population meeting the criteria for a drug and/or alcohol use disorder in 2022 (1). At the same time, youths face enormous challenges in engaging across the entire cascade of substance use care (2). Young adults are generally healthier than older people and have shorter substance use histories and fewer cumulative general medical health conditions, which allows them to tolerate substance use better than older people. Executive functioning is still developing in this age group, and there is a developmental tendency to overestimate one’s own competence, including control over substance use (3). These developmentally based tropes likely contribute to many young adults with a substance use disorder not perceiving a need for treatment (4). Young adults also experience barriers to entering care similar to those faced by older people, including previous bad experience and psychiatric problems, and are more likely to be uninsured compared with older individuals (5). Parents have less leverage over young adults than younger children, and although significant others may step in to fill the void, they generally will have shorter relationship histories, which give their partners less “clout” when compared with older individuals.

“No Wrong Door” Approach to Care

The high co-occurrence of psychiatric and substance use disorders positions psychiatric care as a prime opportunity to address both problems. Patients typically present for treatment of symptoms or conditions that are bothersome to them, and many people feel that substance use is a form of self-medication. Thorough evaluation of a presenting psychiatric symptom includes a substance use history and provides an opportunity to explore motivations for ongoing use and/or reluctance to behavior change and any problems that are experienced with substance use. These conversations may help patients to develop new insights and are a key construct of motivational interviewing. Some patients who deny their substance use may wish to avoid discussing sensitive or stigmatized issues or consider substance use to be a problem too big to tackle. Gentle probing may clarify barriers to addressing substance use for both the provider and the patient.

Medical Treatment

Patient engagement is an important clinical outcome of substance use treatment and continuity of care in the outpatient setting is a mediating factor (6). Nonjudgmental acceptance of autonomy and decision-making can help patients to feel respected and support their ongoing care.

Evaluating and treating the presenting problem can serve as an initial intervention. Substance use has a bidirectional impact on depression, anxiety, and psychotic disorders (7), and treatment for one condition often improves the other. In this sense, treatment for a psychiatric disorder can be a first step toward treating a substance use disorder even among patients who are unwilling to consider changing their substance use.

When patients report their substance use openly, they are displaying a willingness to discuss the issue even if they are not willing to reduce use. Health care professionals can, for example, support risk reduction by prescribing naloxone and encouraging patients to avoid using drugs alone. Health care professionals can refer patients who use drugs to harm reduction services that are available in the community, which may include needle exchanges, safe injection sites, and the provision of fentanyl and xylazine test strips. Pre-exposure prophylaxis, or PrEP, can be offered to patients who use drugs intravenously. Clinicians can also counsel patients that medications for substance use disorder are effective and available should they decide to reduce their use of opioids. In addition to reducing the medical risks associated with substance use, discussion of harm reduction may make a patient who is using drugs feel welcome to return to the office for future medical needs.

Over time, some patients may decide to reduce their drug use. The medical component of substance use disorder treatment can include monitoring for and treating withdrawal symptoms, prescribing medications for substance use disorder treatment, laboratory testing, screening for commonly associated general medical and psychiatric disorders, and providing general counseling, all of which can be accommodated in a psychiatry practice.

Emotional and Behavioral Support

Substance use disorder treatment optimally comprises medical care combined with emotional and behavioral support. Unlike medical treatments, counseling is substance- and, to some extent, diagnosis-agnostic, which allows multiple overlapping issues to be addressed simultaneously. In many cases, substance use will naturally become part of the conversation as patients work on stress, relationships, mood, and other challenges that they are facing. Rapport with a counselor has been shown to improve substance use disorder treatment outcomes (8). Counselors who have established a strong rapport can help patients understand motivations for substance use and barriers to behavior change, teach healthy stress management strategies, talk about avoiding triggers, and manage cravings, stress, and anger, all of which can help prepare patients to consider reducing or discontinuing substance use.

The behavioral component of substance use treatment is typically provided by peers with lived experience who are increasingly integrated into primary care practices (9), and who can guide patients with substance use disorders in learning to re-navigate their communities safely, increase access to support, and provide access to harm reduction services and tools. Peer support can improve relationships with treatment providers and satisfaction with treatment experience (10), and can be helpful even for patients who are not interested in changing their substance use.

Summary

Young adults have low levels of engagement with treatment for substance use disorders. Unpacking the components of treatment and supporting patients to choose among them can help to reduce harm and improve the lives of young adults who use drugs.