Assessing Problematic Substance Use in HIV Care: Which Questions Elicit Accurate Patient Disclosures?

Abstract

BACKGROUND: Substance use is associated with higher rates of antiretroviral non-adherence and poor HIV outcomes. This study examined how HIV care providers assess substance use, and which questions elicit accurate patient disclosures. METHODS: We conducted a conversation analysis of audio-recorded encounters between 56 providers and 162 patients living with HIV (PLWH) reporting active substance use in post-encounter interviews (cocaine or heroin use in the past 30 days, > 4 days intoxicated in past 30 days, or AUDIT score ≥ 8). We assessed the frequency of substance use discussion, characterized the types of questions used by providers, and determined the frequency of accurate patient disclosure by question type. RESULTS: In 55 reports of active substance use, providers already knew about the use (n = 16) or patients disclosed unpromptednn = 39). Among the remaining 155 instances of substance use in which providers had the opportunity to elicit disclosure, 78 reports (50 %) of substance use were not discussed. Of the remaining 77 reports in which the provider asked about substance use, 55 (71 %) patients disclosed and 22 (29 %) did not disclose. Questions were classified as: open-ended (n = 18, BHow's the drinking going?^); normalizing (n = 14, BWhen was the last time you used?^); closed-ended (n = 36, BHave you used any cocaine?^); leading towards non-use (n = 9, BHave you been clean?^). Accurate disclosure followed 100 % of open-ended and normalizing questions, 58 % of closed-ended questions, and 22 % of leading questions. After adjusting for drug type, closed-ended questions were 41 % less likely (p < 0.001), and 'leading' questions 78 % less likely (p = 0.016) than broad and normalizing questions to elicit disclosures. CONCLUSION: Providers in this sample missed almost half of the opportunities to identify and discuss substance use with PLWH. Providers can increase the probability of patient disclosure by using open-ended or normalizing questions that ask about the Blast time^that the patient used drugs or alcohol.

The Impact of Alcohol Use on Antiretroviral Therapy Adherence in Koreans Living with HIV

“…The number of alcohol users in this study was lower than that in previous studies because some HIV-infected Koreans, once aware of the fact that they had been infected, had stopped drinking alcohol and were actively seeking disease control [21]. However, only about half of the providers in an HIV clinic assessed problematic substance usage, including alcohol [22]. In the study by Othieno et al, screening for alcohol use was not routinely performed, and available protocols were not in place to manage alcohol-related disorders [23].…”

“…It is suggested that alcohol screening and treatment, a nonroutine practice in Korea, should be a first step in adherence improvement for people who drink and take antiretroviral drugs, particularly during a stable period of disease progression [24]. When assessing alcohol consumption, an open-ended or normalizing question that includes the phrase "last time," such as "When was the last time you used alcohol?," was proven effective in assessing the alcohol consumption of patients with HIV [22].…”

Measurement of Current Substance Use in a Cohort of HIV-Infected Persons in Continuity HIV Care, 2007–2015

“…Indeed, in another setting characterized by frequent physician-patient interaction (women receiving prenatal care), higher prevalence of cocaine and heroin use was estimated based on medical charts than on face-to-face interview (42). We did not directly explore characteristics of the patient-provider relationship that facilitated physician awareness of substance use; other studies have suggested that patient disclosure of substance use is more likely when physicians use broad or normalizing questions (43), when assessing illicit substance use versus alcohol abuse (41), and in the context of more-frequent provider visits (44). Our estimates of sensitivity and specificity of MRR and SI for detecting recent substance use may be transportable to other HIV clinics, given lack of evidence that sensitivity varied by patient demographics, but are not likely transportable to general practice settings.…”

Adolescent and young adult women’s recommendations for establishing comfort with family planning providers’ communication about and assessment for intimate partner violence

“…Our participants' perspectives and advice on creating patient comfort in clinic-based IPV assessment can translate to other sensitive topics such as palliative and end of life care and often-stigmatized areas like HIV or other sexually transmitted infection treatment. We suggest that emphasizing emotional comfort patient comfort can be a beneficial addition to the existing patient-centered and open-ended communication methods that are already commonly applied in these areas [82][83][84][85].…”