Care of People Who Show Unhealthy Substance Use
The spectrum of use
Unhealthy use spans risky use, harmful use, and SUD. Screening and brief intervention (SBI) is the core primary-care skill: ask, assess, advise, assist, arrange. Motivational interviewing - open questions, affirmations, reflections, summaries - is preferred over confrontation. The candidate should distinguish screening (identify risk) from assessment (characterize pattern and consequences) from intervention (change behavior).
Special populations and prescribed medications
Know that older adults metabolize alcohol and benzodiazepines more slowly and are at higher fall and cognitive risk. Pregnancy: alcohol is teratogenic; opioid use disorder in pregnancy is treated with methadone or buprenorphine, not withdrawal. Adolescents: brief interventions and family involvement are key. Prescription medication misuse (opioids, benzodiazepines, stimulants) requires review of prescribing, PDMP use, and tapering plans when appropriate. Nicotine: ask, advise, and offer pharmacotherapy plus counseling at every visit.
Harm reduction
Harm reduction is evidence-based and complements treatment: naloxone distribution, syringe services, fentanyl test strips, and safe consumption education reduce death and infection without requiring abstinence.
Traps
Questions often test that brief intervention is appropriate for risky use but insufficient for severe SUD, that motivational interviewing avoids confrontation, and that harm reduction is not antithetical to treatment.
Rule of thumb: match the intervention to the stage - screen everyone, briefly intervene for risky use, and refer to treatment for SUD.