Open-Ended and Normalizing Questions Elicit More Accurate Disclosure of Substance Use in HIV Care

Among patients living with HIV (PLWH), substance use is associated with non-adherence to antiretroviral therapy (ART) and poor outcomes. To determine the best method for eliciting accurate disclosure of substance use among PLWH, this qualitative study analyzed medical encounters between 56 HIV healthcare providers and 162 PLWH who reported past-month cocaine, heroin, or heavy alcohol use in a post-encounter interview.

• Substance use was not discussed in 78 encounters (50%).
• In 16 encounters (10%), providers already knew about the substance use; patients disclosed without prompting in 39 (24%).
• Providers asked about substance use with questions that were open-ended (e.g., “How’s your drinking going?”) in 18 encounters (11%); normalizing queries (e.g., “When was the last time you used?”) in 14 cases (9%); closed-ended in 36 (22%); and questions “leading toward non-use” in 9 (6%).
• Disclosure of substance use ensued with all open-ended or normalizing queries, but only 58% of closed-ended and 22% of leading toward non-use questions.
• Adjusting for substance type, closed-ended (relative risk [RR], 0.60) and leading questions (RR, 0.22) were significantly less likely to elicit truthful disclosure.

Comments:

This study demonstrates that how clinicians inquire influences patients’ willingness to disclose substance use. Open-ended or normalizing questions (such as those in validated screening tools) are likely associated with the non-judgmental, curious, and empathic attitude that is essential to gaining the trust of patients with substance use issues. Approaches grounded in motivational interviewing suggest that asking permission (“May I ask you about your substance use?”) and using eliciting statements rather than questions (“Please tell me about your drinking”) might further promote candid discussions.

Peter D. Friedmann, MD, MPH

Reference:

Callon W, Beach MC, Saha S et al. Assessing problematic substance use in HIV care: which questions elicit accurate patient disclosures? J Gen Intern Med. 2016;31(10):1141–1147.