Samet et al recommended steps for approaching the patient with a positive screening questionnaire for substance abuse. This can help determine the severity of the problem and the readiness of the patient to change. The authors are from Boston University, the University of Wales, and Cambridge Hospital (Massachusetts).


Interview questions:

(1) Ask about details of adverse consequences from the substance abuse to:

(1a) family

(1b) work

(1c) social relationships

(1d) health (including injuries and accidents)

(1e) legal (driving problems, fighting, disorderly behavior)

(2) Ask about loss of control when using primary substances

(2a) feelings of being out control

(2b) inability to stop once started

(3) Determine the patient’s perception of the problem.

(4) Determine how capable the patient feels about changing the behavior.

(5) Assess the patient’s readiness to change behavior.



• I added “legal” under adverse consequences and the 2 subitems under loss of control.


Readiness to Change (after Prochaska and Diclemente)



denies there is a problem


ambivalent but considering the need to change


has made the decision to stop


receiving treatment and actively abstaining


in recovery


return to an earlier pre-action stage



• Sometimes a person who is about to relapse may do things that indicate a weakening of resolve (like buying liquor for friends, or returning to old bar hangouts).


Interview Approaches


Express concern.

State nonjudgmentally that the abuse is a problem.

Agree to disagree about the severity of the problem.

Suggest a trial of abstinence to clarify the issue.

Suggest bringing a family member to an appointment.

Explore the patient’s perception of the problem.

Emphasize the importance of being seen again.


Elicit positive and negative aspects of substance use.

Ask about previous episodes of abstinence and the positive and negative aspects.

Summarize the patient’s comments.

Make explicit the discrepancies between values and actions.

Encourage a trial of abstinence.


Acknowledge the significance of the decision.

Support self-efficacy.

Affirm the patient’s ability to successfully seek treatment.

Help the patient decide on an appropriate, achievable action.

Caution that the process is difficult but essential.

Explain that relapse should not disrupt the patient-physician relationship.


Encourage and support.

Acknowledge the discomfort during withdrawal.

Reinforce the need to remain in recovery.


Anticipate difficulties.

Recognize the patient’s struggle.

Support the patient’s resolve.

Reiterate that relapse should not disrupt the patient-physician relationship.


Express concern about the relapse.

Explore what can be learned from the relapse.

Emphasize the positive aspect of the effort to seek care.

Encourage the patient to seek care.

Support the patient’s self-efficacy so that recovery seems achievable.

modified from Table 3, page 2291


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