February 2017 

Eliciting accurate responses about substance use

Achieving and maintaining an undetectable viral load requires a high degree of adherence to potent combination anti-HIV therapy (ART). For some people this may be relatively easy. However, for other people, for a variety of reasons, adherence to ART and other medicines may be difficult. This problem can arise because of competing priorities, including issues such as undiagnosed depression and problematic substance use. This latter issue carries societal disapproval, so some people may find it difficult to disclose substance use to their doctor, nurse or pharmacist. Substances can directly or indirectly affect a person’s mood and emotional state, and problematic substance use can affect adherence and ultimately a person’s health. Researchers are finding that problematic substance use is linked to poorer health and reduced survival among HIV-positive people.

Researchers in four U.S. cities—Baltimore, Detroit, New York and Portland—conducted a study to help understand interactions between healthcare providers and their HIV-positive patients. In particular, the researchers sought to assess the types of questions used by healthcare providers. They found that when healthcare providers formulated questions in a manner that did not convey judgment or even subtle bias, accurate disclosure of substance use occurred. We reproduce their categories of questions later in this report.

Study details

Researchers sought and received written consent to record the conversations between healthcare practitioners and their patients. After a patient’s appointment with a practitioner, researchers also interviewed the patient and asked them detailed questions about substance use.

Upon entering the study, the average profile of participants (healthcare providers and patients) was as follows:

56 healthcare providers

  • age – 44 years
  • 46% men, 54% women
  • professions: physician – 65%; nurse practitioner – 20%; physician assistant – 15%

162 patients

  • age – 47 years
  • 58% men, 42% women
  • substances used included the following: alcohol only – 33%; cocaine only – 35%; heroin only – 6%; more than one substance – 25%


According to the researchers, healthcare providers were aware of 52% of instances of substance use at the end of their patients’ visit. Conversely, the researchers stated that healthcare practitioners “remained apparently unaware of [48%] of instances of substance use.”

More than one substance

Although there were 41 patients who disclosed the use of more than one substance to the research team, the researchers found that healthcare providers were able to “fully elicit disclosures of all substance use in only 29% of encounters” with patients who used more than one substance. In these 29% of encounters, the researchers stated that “disclosure of cocaine tended to be higher than that of alcohol or heroin.”

Types of questions

Researchers identified four categories of questions, which they described in the following way:


“These were questions that invited the patient to be elaborate in their response and cannot be answered with just one word.”


These were questions that asked specifically about the last time a patient used drugs or alcohol.


These were “positively framed” questions that named a substance of interest or more generally referred to a substance using specific names.

Leading toward non-use

These questions were “negatively framed” with phrases such as “not using” or “staying clean.”

Eliciting accurate disclosure

The researchers found that open-ended and normalizing questions resulted in accurate disclosure of substance use in all cases.

Furthermore, the researchers stated that “problematic substance use is a sensitive topic with significant surrounding stigma. Open-ended questions may create a sense of less judgment and greater comfort for the patient, reducing response bias.”

The researchers said that asking about the “last time” a patient used a substance “normalizes substance use and thus may lower the barrier for disclosure.” They added that framing a question in this way “may prompt more accurate recall by giving a specific reference point, increasing disclosure rates.”

Not getting the right information

In contrast to the previous types of questioning, the researchers found that asking “leading questions,” such as those that enquire whether the patient is “staying clean” or “not using,” makes the questions acquire a subtle but threatening nature and makes substance use “seem less acceptable.” Such questions only serve to underscore the stigma attached to substance use and may undermine disclosure “for fear of blame or judgment.”

More than one substance

Based on their findings, the researchers encouraged healthcare practitioners to “ask about other substances when one is disclosed.”

Getting to ask

The researchers found that nearly half of healthcare providers did not ask their patients about substance use. To remedy this situation, they encouraged the following course of action:

“It may be worth considering implementation of a universal screening program to increase patient disclosure rates. For example, using [written or tablet-enabled] surveys in the waiting room may lead to greater disclosure without relying on providers to ask about substance use during the clinical encounter.”

Bear in mind

Note that the present study was observational in nature. Therefore, there may be factors that were not measured or accounted for by the researchers that could have inadvertently biased their conclusions. For instance, according to the researchers, some patients and care providers have a “more functional” relationship that affected the type of question used. Also, the researchers stated that their study was too small to draw meaningful (that is, statistical) relationships around questions asked and about the race, gender or other attributes of the healthcare providers and their patients.


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