Harm Reduction Approach to Treatment of All Substance Use Disorders

Harm Reduction Approach to Treatment of All Substance Use Disorders

Purpose and Development of This Guideline

Lead Author: Sharon Stancliff, MD, with the Substance Use Guideline Committee, August 2019

This guideline on a harm reduction approach to the treatment of substance use disorder (SUD) was developed by the New York State (NYS) Department of Health (DOH) AIDS Institute (AI) to guide primary care providers and other practitioners in NYS in treating patients with a substance use disorder.

This guideline aims to:

  • Increase the number of clinicians in outpatient settings offering evidence-based treatment to individuals with a substance use disorder.
  • Increase the number of NYS residents with substance use disorders who are engaged in treatment.
  • Promote a harm reduction approach to treatment of all substance use disorders, which involves practical strategies and ideas aimed at reducing the negative consequences associated with drug and alcohol use (e.g., needle and syringe exchange for individuals who inject drugs).
  • Increase awareness among healthcare providers about the stigma associated with substance use.

Role of NYS Primary Care Providers in the Treatment of Substance Use Disorders

Primary care providers in NYS play an essential role in identifying and treating substance use disorders in their patients. Effective treatments that can be delivered in an outpatient setting are available for many SUDs, including tobacco, alcohol, and opioids, which increases treatment access. A substance use disorder is a long-term, chronic condition and, like other chronic conditions, can be successfully managed in a primary care setting.

This guideline recommends a harm reduction approach to SUD treatment that can be adopted by primary care providers and clinicians in all other treatment settings. A harm reduction approach promotes positive changes beyond abstinence, including reduction in substance use, safer use, and other lifestyle changes. This approach also emphasizes that clinicians should avoid coercion, discrimination, and bias when working with individuals with SUD.

Guideline Development

This guideline was developed by the NYSDOH AI Clinical Guidelines Program, which is a collaborative effort between the NYSDOH AI Office of the Medical Director and the Johns Hopkins University (JHU) School of Medicine, Division of Infectious Diseases.

Established in 1986, the goal of the Clinical Guidelines Program is to develop and disseminate evidence-based, state-of-the-art clinical practice guidelines to improve the quality of care throughout NYS for people who have HIV, hepatitis C virus, or sexually transmitted infections; people with substance use issues; and members of the LGBTQ community. NYSDOH AI guidelines are developed by committees of clinical experts through a consensus-driven process.

The NYSDOH AI SUD Guideline Committee was charged with developing evidence-based clinical recommendations for primary care providers in NYS who treat patients who have SUDs. The resulting recommendations are based on an extensive review of the medical literature and reflect consensus among this panel of SUD experts. Each recommendation is rated for strength and for quality of the evidence (see below). If recommendations are based on expert opinion, the rationale for the opinion is included. See About the Substance Use Disorder Guidelines for a full description of the development process, including evidence collection and recommendation development.

AIDS Institute HIV Clinical Guidelines Program Recommendations Rating Scheme
Strength of Recommendation Quality of Supporting Evidence
A = Strong 1 = At least 1 randomized trial with clinical outcomes and/or validated laboratory endpoints
B = Moderate 2 = One or more well-designed, nonrandomized trial or observational cohort study with long-term clinical outcomes
C = Optional 3 = Expert opinion

Definition of Terms

Lead Author: Sharon Stancliff, MD, with the Substance Use Guideline Committee, August 2019

Box 1: Terms Used in This Guideline
Substance use Alcohol or drug use.
Illicit drug use Use of non-prescription medication or drug.
Substance use disorder (SUD) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis.
SUD treatment Pharmacologic, psychosocial, or harm reduction intervention for individuals with SUD.
Pharmacologic treatment Replaces “medication-assisted treatment” (MAT).
Medication Pharmacologic agent used to treat SUD (e.g., methadone).
Harm reduction In the clinical context, harm reduction is an approach and a set of practical strategies targeted to reduce the negative consequences associated with substance use. It is founded on respect for and the rights of those individuals who use drugs [adapted from the Harm Reduction Coalition]. For strategies, see Box 2: Harm Reduction Counseling in the Medical Setting.

Harm Reduction in Treatment of Substance Use Disorders

Lead Author: Sharon Stancliff, MD, with the Substance Use Guideline Committee, August 2019

The NYSDOH AI and this Committee strongly advocate a harm reduction approach in the care of all individuals who use substances, including those with a diagnosed substance use disorder (SUD). The recommendations below are based on emerging evidence and the extensive clinical experience of this Committee. For NYS-specific information on harm reduction, please see NYSDOH Harm Reduction Services.

RECOMMENDATIONS
Harm Reduction in Treatment of Substance Use Disorders
  • For patients who use substances, whether or not they are engaging in substance use disorder treatment, clinicians should continue to offer medical care and offer or refer for harm reduction services and counseling on safer substance use. (A3)
  • For patients who inject drugs, clinicians should:

For individuals who use substances, regardless of their interest in treatment, it is important to provide ongoing medical care and to provide or refer for harm reduction services. Harm reduction services are particularly important for those who do not choose to reduce or stop substance use. Examples of harm reduction counseling are described in Box 2, below. If individuals are seen only intermittently in a healthcare setting, any visit can provide an opportunity to offer brief medical services, such as offering vaccinations, providing sexual health services, and other primary care services.

For individuals who inject drugs, harm reduction includes provision of or referral for sterile needles and syringes [Bowman, et al. 2013]. Sharing injection equipment can transmit bloodborne diseases, such as HIV and HCV; in the United States, injection drug use is the leading cause of HCV infection [CDC 2018]. Unsterile injection equipment is also associated with soft tissue infections, including methicillin-resistant Staphylococcus aureus (MRSA), Candida albicans, and Staphylococcus aureus [Hartnett, et al. 2019]. Syringe access has been associated with dramatic reductions in HIV transmission; as syringe exchange was expanded in New York City, HIV seroincidence decreased to 1/100 person years (PY) from 4/100 PY [Des Jarlais and Carrieri 2016]. Syringe exchange also has been associated with reductions in HCV transmission [Des Jarlais, et al. 2005; Saab, et al. 2018].

Box 2: Harm Reduction Counseling in the Medical Setting

Examples of harm reduction counseling:

  • Discussing the risks of alcohol and substance use while driving. Many people do not recognize that cannabis use can impair driving skills [Wadsworth and Hammond 2018], particularly when mixed with alcohol [Smart, et al. 2018].
  • Addressing the substance(s) that the individual uses and other substances that may be used by people in the individual’s family or social network so the patient can pass on information about harm reduction.
  • Informing individuals who use drugs that fentanyl, a common and often unidentified additive to heroin, is much more potent than heroin and can increase the likelihood of a fatal overdose. It is important to inform patients who use drugs that, to avoid a fentanyl overdose, they should start with a small amount, carry naloxone (NLX) to reverse opioid overdoses, and avoid mixing drugs [Colon-Berezin, et al. 2019].
    • Some individuals who use drugs other than opioids may also be at risk of opioid overdose. In New York City, fentanyl has been identified in illicit cocaine and methamphetamine samples and has also been found in counterfeit pills that are made to look like various opioid analgesics and benzodiazepines [Colon-Berezin, et al. 2019].
  • Informing individuals that the risk of an accidental fatal overdose can be reduced if they avoid injecting/using alone.
  • Describing the role of NLX in the setting of an opioid overdose and ensuring that all individuals who use opioids and the people close to them know how to access and use NLX.
  • Advising individuals who inject drugs to avoid sharing any injection equipment and, if possible, to avoid reusing any equipment.
  • Informing individuals who are not currently injecting, but who use drugs that can be injected, how to obtain syringes.
References

Bowman S, Eiserman J, Beletsky L, et al. Reducing the health consequences of opioid addiction in primary care. Am J Med 2013;126(7):565-571. [PMID: 23664112]

CDC. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance—United States, 2016. 2018 https://www.cdc.gov/hepatitis/statistics/2016surveillance/index.htm [accessed July 2, 2019]

Colon-Berezin C, Nolan ML, Blachman-Forshay J, et al. Overdose deaths involving fentanyl and fentanyl analogs – New York City, 2000-2017. MMWR Morb Mortal Wkly Rep 2019;68(2):37-40. [PMID: 30653482]

Des Jarlais DC, Carrieri P. HIV infection among persons who inject drugs: ending old epidemics and addressing new outbreaks: authors’ reply. AIDS 2016;30(11):1858-1859. [PMID: 27351930]

Des Jarlais DC, Perlis T, Arasteh K, et al. Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990-2001. AIDS 2005;19 Suppl 3:S20-25. [PMID: 16251819]

Hartnett KP, Jackson KA, Felsen C, et al. Bacterial and Fungal Infections in Persons Who Inject Drugs – Western New York, 2017. MMWR Morb Mortal Wkly Rep 2019;68(26):583-586. [PMID: 31269011]

Saab S, Le L, Saggi S, et al. Toward the elimination of hepatitis C in the United States. Hepatology 2018;67(6):2449-2459. [PMID: 29181853]

Smart R, Osilla KC, Jonsson L, et al. Differences in alcohol cognitions, consumption, and consequences among first-time DUI offenders who co-use alcohol and marijuana. Drug Alcohol Depend 2018;191:187-194. [PMID: 30130715]

Wadsworth E, Hammond D. Differences in patterns of cannabis use among youth: Prevalence, perceptions of harm and driving under the influence in the USA where non-medical cannabis markets have been established, proposed and prohibited. Drug Alcohol Rev 2018;37(7):903-911. [PMID: 29992695]

Implementing a Harm Reduction Treatment Plan

Lead Author: Sharon Stancliff, MD, with the Substance Use Guideline Committee, August 2019

RECOMMENDATIONS
Implementing a Harm Reduction Treatment Plan
  • Clinicians should collaborate with patients to set specific treatment goals (A3); goals other than full abstinence are acceptable (e.g., changes in use resulting in increased well-being and decreased harm or potential harm). (A3)
  • To assist patients in planning and reaching treatment goals, clinicians should ask about the role and effects of substance use in their daily lives. (A3)
  • Clinicians and patients should decide on an appropriate level of care (e.g., venue and/or intensity) based on: (B3)
    • Medically recommended treatment for the patient’s substance use disorder(s).
    • The patient’s need for support and other services, such as medical and mental health care and psychosocial support.
    • Availability of care.
    • Patient preference.
  • For patients with a substance use disorder, clinicians should offer pharmacologic treatment when it is indicated. (A3)
  • Clinicians should not discontinue substance use disorder treatment due solely to recurrences or continuation of use. (A3)

Traditionally, substance use disorder (SUD) treatment providers have considered abstinence the primary goal of treatment, but this approach is evolving. Changing the pattern of or reducing an individual’s substance use has measurable health benefits and contributes to increased function, even if the individual continues to use the substance of choice or other substances [Gjersing and Bretteville-Jensen 2013; Collins, et al. 2015a; Collins, et al. 2015b; Charlet and Heinz 2017; Lea, et al. 2017].

For some individuals with a substance use disorder, use of other substances can reduce use of the more problematic substance. There is increasing interest in the use of cannabis, cannabidiol, and other substances to reduce the compulsion to use opioids [Socias, et al. 2017; Chye, et al. 2019]. This is important to consider for individuals with opioid use disorder (OUD) who, if untreated, are at increased risk for overdose and death.

KEY POINTS: FENTANYL
  • Fentanyl is a common and often unidentified additive to heroin and other drugs [Colon-Berezin, et al. 2019]. In New York City, it has been found in samples of cocaine, methamphetamine, and in counterfeit pills that look like various opioid analgesics and benzodiazepines.
  • Because fentanyl is much more potent than heroin, it can increase the likelihood of a fatal overdose.
  • It is important to advise individuals who use drugs how to avoid a fentanyl overdose: start with a small amount of a drug, carry NLX to reverse an opioid overdose if it occurs, and avoid mixing drugs.

Working with a patient who has a substance use disorder to implement an appropriate treatment plan involves balancing a number of factors, and the choice of treatment may be limited by availability and other practical considerations. Some individuals may perceive substance use to be more helpful or pleasurable than harmful. Asking about and understanding the perceived benefits of substance use can help the clinician identify other ways for the patient to obtain the same or similar benefits and tailor a successful treatment plan.

A range of effective pharmacologic treatment is available for several SUDs, including alcohol [Overman, et al. 2003; Rosner, et al. 2010; Jonas, et al. 2014], tobacco [Piper, et al. 2009; Anthenelli, et al. 2016], and opioid use disorders [Mattick, et al. 2014; Lee, et al. 2018]. Clinicians should discuss pharmacologic treatments with patients and help them understand the benefits and risks. In NYS, most drug treatment programs licensed by the Office of Alcoholism and Substance Abuse Services (OASAS) are mandated to provide pharmacotherapy when indicated [OASAS 2016]. Some patients may misunderstand or have biases against pharmacologic treatment, so it may be helpful to continue these discussions over time. It is also important for clinicians to inform patients about the different treatment settings available (see Box 3, below).

Box 3: Substance Use Disorder Treatment Settings
  • Office-based services: A variety of settings (e.g., primary care, psychiatry), including pharmacologic treatment.
  • Medically managed, monitored, or supervised withdrawal and stabilization: Includes inpatient and outpatient settings and should be followed by additional treatment.
  • Outpatient services: Includes counseling, educational group sessions, and other services; the length and intensity of treatment vary.
  • Opioid treatment programs (e.g., methadone programs): Includes outpatient services, medical assessment, and pharmacologic treatment.
  • Residential treatment: Includes a variety of programs from inpatient, medically supervised programs to supportive housing.

Adapted from OASAS: Substance Use Disorder Service Descriptions.

Clinicians should not deny or discontinue SUD treatment if a patient continues to or returns to use because the patient may still benefit from treatment [Gjersing and Bretteville-Jensen 2013]. In 2017, the U.S. Food and Drug Administration issued a Drug Safety Communication urging caution in denying methadone or buprenorphine when patients are taking benzodiazepines because the risk of opioid overdose is higher with no treatment than the risks of combining the medications [FDA 2017]. Instead, healthcare providers may consider intensifying SUD treatment, such as increasing frequency of visits, offering psychosocial treatment, or adding mental health treatment.

SUD is a chronic health condition that requires long-term management, including pharmacologic treatment [Saitz, et al. 2013]. It is important to continue treatment for as long as it is beneficial to a patient. Patients may opt to discontinue medication, but clinicians should encourage treatment resumption without suggesting failure or implying that no pharmacologic treatment is the preferred approach.

KEY POINTS
  • Substance use disorder is a chronic health condition that requires long-term management, including pharmacologic treatment.
  • SUD treatment medications and other treatments should not be denied or discontinued in individuals with SUD if or when they continue or return to use because patients may continue to benefit from treatment [Gjersing and Bretteville-Jensen 2013].
  • If the criminal justice system or other entities, such as child welfare services, discontinue an individual’s OUD treatment plan, it is important for clinicians to advocate for their patient to continue their pharmacologic treatment plan.

Individualized follow-up during outpatient substance use disorder treatment: Ongoing, regular follow-up is essential for support, encouragement, and modification of the treatment plan as needed.

  • Follow-up within 2 weeks of treatment initiation allows tailoring of the treatment plan (e.g., change in dose of pharmacologic treatment, addition of support services) according to individual needs.
  • As individuals stabilize on treatment, monthly or at least quarterly follow-up allows for ongoing evaluation to ensure that the patient’s goals are being met.

As with all diseases and disorders, patients who have a substance use disorder may present with medical complexities beyond a clinician’s expertise. Adolescents may require specialty care, as may individuals who are pregnant or who have co-occurring psychiatric disorders. When individual patient factors may complicate diagnosis and treatment, local and national resources are available for consultation and referral. For opioid-related issues, the Providers Clinical Support System (PCSS) is a national resource for clinicians.

References

Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet 2016;387(10037):2507-2520. [PMID: 27116918]

Charlet K, Heinz A. Harm reduction-a systematic review on effects of alcohol reduction on physical and mental symptoms. Addict Biol 2017;22(5):1119-1159. [PMID: 27353220]

Chye Y, Christensen E, Solowij N, et al. The Endocannabinoid System and Cannabidiol’s Promise for the Treatment of Substance Use Disorder. Front Psychiatry 2019;10:63. [PMID: 30837904]

Collins SE, Duncan MH, Smart BF, et al. Extended-release naltrexone and harm reduction counseling for chronically homeless people with alcohol dependence. Subst Abus 2015a;36(1):21-33. [PMID: 24779575]

Collins SE, Grazioli VS, Torres NI, et al. Qualitatively and quantitatively evaluating harm-reduction goal setting among chronically homeless individuals with alcohol dependence. Addict Behav 2015b;45:184-190. [PMID: 25697724]

Colon-Berezin C, Nolan ML, Blachman-Forshay J, et al. Overdose deaths involving fentanyl and fentanyl analogs – New York City, 2000-2017. MMWR Morb Mortal Wkly Rep 2019;68(2):37-40. [PMID: 30653482]

FDA. U.S. Food and Drug Administration. FDA urges caution about withholding opioid addiction medications from patients taking benzodiazepines or CNS depressants: careful medication management can reduce risks. 2017 https://www.fda.gov/Drugs/DrugSafety/ucm575307.htm [accessed May 20, 2019]

Gjersing L, Bretteville-Jensen AL. Is opioid substitution treatment beneficial if injecting behaviour continues? Drug Alcohol Depend 2013;133(1):121-126. [PMID: 23773951]

Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA 2014;311(18):1889-1900. [PMID: 24825644]

Lea T, Kolstee J, Lambert S, et al. Methamphetamine treatment outcomes among gay men attending a LGBTI-specific treatment service in Sydney, Australia. PLoS One 2017;12(2):e0172560. [PMID: 28207902]

Lee JD, Nunes EV, Jr., Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet 2018;391(10118):309-318. [PMID: 29150198]

Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014;(2):Cd002207. [PMID: 24500948]

OASAS. New York State Office of Alcoholism and Substance Abuse Services Treatment Services: General provisions. Title 14 NYCRR Part 800. July 27, 2017. 2016 https://www.oasas.ny.gov/legal/documents/Part800.pdf [accessed July 16, 2019]

Overman GP, Teter CJ, Guthrie SK. Acamprosate for the adjunctive treatment of alcohol dependence. Ann Pharmacother 2003;37(7-8):1090-1099. [PMID: 12841823]

Piper ME, Smith SS, Schlam TR, et al. A randomized placebo-controlled clinical trial of 5 smoking cessation pharmacotherapies. Arch Gen Psychiatry 2009;66(11):1253-1262. [PMID: 19884613]

Rosner S, Hackl-Herrwerth A, Leucht S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev 2010;(12):CD001867. [PMID: 21154349]

Saitz R, Cheng DM, Winter M, et al. Chronic care management for dependence on alcohol and other drugs: the AHEAD randomized trial. JAMA 2013;310(11):1156-1167. [PMID: 24045740]

Socias ME, Kerr T, Wood E, et al. Intentional cannabis use to reduce crack cocaine use in a Canadian setting: A longitudinal analysis. Addict Behav 2017;72:138-143. [PMID: 28399488]

Reducing Stigma

Lead Author: Sharon Stancliff, MD, with the Substance Use Guideline Committee, August 2019

RECOMMENDATIONS
Reducing Stigma
  • Clinicians should examine their assumptions and decisions for any personal biases that may affect their ability to provide effective care for individuals who use substances. (A3)
  • Clinicians and other staff interacting with patients should use neutral terms to describe all aspects of substance use and avoid language that perpetuates stigma (see Box 4: Changing the Language of Substance Use: Use Neutral Terms). (A2)

It is often a challenging task for clinicians to recognize and set aside personal biases and to address biases with peers and colleagues. Clinician bias has been associated with health disparities [Hall, et al. 2015; FitzGerald and Hurst 2017] and can have profoundly negative effects. Consciously or unconsciously, negative or stigmatizing assumptions are often made about patient characteristics, such as race, ethnicity, gender, sexual orientation, mental health, and substance use [Livingston, et al. 2012; van Boekel, et al. 2013; Avery, et al. 2019]. Individuals who use substances may also be stigmatized by assumptions about substance use and criminal behavior. For more information, see:

To acknowledge and address stigma, clinicians are advised to consciously change their substance use-related vocabulary to avoid stigmatizing terms, to use neutral medical terms instead, and to help colleagues and staff adopt neutral language (see Box 4, below). For example, the term “dirty urine test” elicits a more negative reaction toward a patient than the more accurate and neutral term “opiate-positive test result” [Kelly JF and Westerhoff 2010]. Patients may choose to use stigmatized words in describing themselves, but clinicians and staff should strive to use language that is respectful of the individual and easy to understand.

Box 4: Changing the Language of Substance Use: Use Neutral Terms*
Stigmatizing Terms Neutral Alternative
Substance abuse Substance use
Drug addict, drug abuser, alcoholic, junkie, crackhead, tweaker, etc. A person who uses drugs, alcohol, or substances
“Clean” or “dirty” toxicology results

“Negative” or “positive” toxicology results
“Unexpected” or “expected” results
Got clean A person who formerly used drugs or alcohol
Relapse A recurrence of use or “return” to use

*Kelly J, et al. 2016. For additional terms and definitions see Addictionary.
References

Avery JD, Taylor KE, Kast KA, et al. Attitudes Toward Individuals With Mental Illness and Substance Use Disorders Among Resident Physicians. Prim Care Companion CNS Disord 2019;21(1). [PMID: 30620451]

FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017;18(1):19. [PMID: 28249596]

Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health 2015;105(12):e60-76. [PMID: 26469668]

Kelly J, Saitz R, Wakeman S. Language, substance use disorders, and policy: The need to reach consensus on an “addiction-ary”. Alcohol Treatment Quarterly 2016;34(1):116-123.

Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy 2010;21(3):202-207. [PMID: 20005692]

Livingston JD, Milne T, Fang ML, et al. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction 2012;107(1):39-50. [PMID: 21815959]

van Boekel LC, Brouwers EP, van Weeghel J, et al. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend 2013;131(1-2):23-35. [PMID: 23490450]

All Recommendations

Lead Author: Sharon Stancliff, MD, with the Substance Use Guideline Committee, August 2019

ALL RECOMMENDATIONS: HARM REDUCTION APPROACH TO TREATMENT OF ALL SUBSTANCE USE DISORDERS
Harm Reduction in Treatment of Substance Use Disorders
  • For patients who use substances, whether or not they are engaging in substance use disorder treatment, clinicians should continue to offer medical care and offer or refer for harm reduction services and counseling on safer substance use. (A3)
  • For patients who inject drugs, clinicians should:
Implementing a Harm Reduction Treatment Plan
  • Clinicians should collaborate with patients to set specific treatment goals (A3); goals other than full abstinence are acceptable (e.g., changes in use resulting in increased well-being and decreased harm or potential harm). (A3)
  • To assist patients in planning and reaching treatment goals, clinicians should ask about the role and effects of substance use in their daily lives. (A3)
  • Clinicians and patients should decide on an appropriate level of care (e.g., venue and/or intensity) based on: (B3)
    • Medically recommended treatment for the patient’s substance use disorder(s).
    • The patient’s need for support and other services, such as medical and mental health care and psychosocial support.
    • Availability of care.
    • Patient preference.
  • For patients with a substance use disorder, clinicians should offer pharmacologic treatment when it is indicated. (A3)
  • Clinicians should not discontinue substance use disorder treatment due solely to recurrences or continuation of use. (A3)
Reducing Stigma
  • Clinicians should examine their assumptions and decisions for any personal biases that may affect their ability to provide effective care for individuals who use substances. (A3)
  • Clinicians and other staff interacting with patients should use neutral terms to describe all aspects of substance use and avoid language that perpetuates stigma (see Box 4: Changing the Language of Substance Use: Use Neutral Terms). (A2)