We use the disease model and approach each separately. For example, if we have a patient with diabetes and asthma, we won’t stop treating the diabetes if they start smoking again and the asthma gets worse. Likewise, we try not to tie buprenorphine treatment to poorly controlled cocaine or alcohol use disorder. The other rationale for the harm reduction approach as opposed to the abstinence model is that the longer someone is in treatment the higher the odds of them getting better. We use motivational interviewing and try to let natural consequences be a platform for discussion. We also use relapse prevention groups and we see people more frequently if they continue to use other substances to try to provide an incentive to decrease use. Often, we will require group 3x weekly along with weekly scripts with the aim of helping them reduce use.
We get a urine test as early as possible since many people don’t expect it the first visit. That helps us understand what substances we need to be concerned about. We will still enroll people with other substance misuse but advise them we will be dealing with their other substance problems and we won’t be able to progress (to monthly scripts for example) if those don’t improve. We get releases from their other physicians. We won’t treat if they won’t let us talk to their physician and we prefer to take over all their psychiatric prescriptions. We also use mouth swabs on occasion as those are harder to alter – not to be punitive but to understand the problem. And we let them know the dangers of combining substances. A huge risk factor for any substance use disorder is untreated ADHD so we do want to treat it, if it is legitimate but we do need to be meticulous with the diagnosis and with ongoing monitoring to make sure that amphetamines are being used therapeutically. We try to document functional improvement with the amphetamines and use the ones with the lowest abuse potential.
