How to approach a discussion with an adult patient with a history of substance abuse and potential underlying mental health issues about a positive cocaine drug screen?

Approaching a Discussion About a Positive Cocaine Drug Screen

Use motivational interviewing techniques with open-ended, non-confrontational questions that elicit the patient's own concerns and goals, rather than directing them what to do—this approach has been shown to decrease substance use frequency and quantity. 1

Initial Interview Framework

Start with Open-Ended Exploration (Not Confrontation)

• Ask: "What do you know about how cocaine affects your health?" rather than telling them cocaine is damaging them 1
• Ask: "What do you like about using cocaine?" to understand their perspective without judgment 1
• Follow with: "What do you not like about cocaine use? What makes you think about stopping?" to elicit their own concerns 1
• Avoid statements like "You need to stop using cocaine" as this triggers defensiveness and is less effective 1

Elicit Their Knowledge, Then Provide Tailored Information

• After hearing their understanding, provide specific health information: "Even small amounts of cocaine increase your risk of heart attack, stroke, and high blood pressure. Sometimes people have heart attacks from using cocaine just one time." 1
• Then ask: "How does that new information strike you?" to gauge their response 1
• This sequence (elicit → inform → elicit response) is more effective than lecturing 1

Assess Pattern and Severity

Ask specific questions to stratify use into hazardous use, substance abuse, or substance dependence: 1

• Frequency and duration: "How many times in the past year have you used cocaine?" 1
• Impact on functioning: "Has cocaine use resulted in missing work, school obligations, or neglecting family?" 1
• Risky situations: "Have you used cocaine in physically hazardous situations like driving?" 1
• Legal problems: "Have you had any arrests or legal issues related to cocaine?" 1
• Continued use despite problems: "Have you continued using despite social or relationship problems it's caused?" 1

Note that cocaine use is intrinsically high-risk for harm to self and others, even with infrequent use. 1

Screen for Co-occurring Psychiatric Conditions

• Evaluate for depression, bipolar disorder, schizophrenia, and anxiety disorders, as these are common in patients with cocaine use disorders 2, 3
• Ask about suicidal ideation, particularly in young males with cocaine use 1
• Assess whether psychiatric symptoms preceded or followed cocaine use 2

Assess Medical Complications

• Ask about chest pain, palpitations, or shortness of breath (cocaine causes coronary spasms, tachycardia, and hypertension even with small amounts) 2, 4
• Inquire about nasal symptoms if intranasal use is suspected 1
• Screen for other substance use, particularly alcohol (polysubstance use is common) 1

Collaborative Treatment Planning

Explore Their Treatment Preferences

• Ask: "What do you think would work for you?" rather than imposing a treatment plan 1
• If they resist formal treatment, explore alternatives: "If drug treatment isn't for you, what about medication options or support groups like NA?" 1
• This collaborative approach increases engagement 1

Reinforce Self-Efficacy After Relapse

• If discussing a relapse, say: "You're frustrated, but the fact that you came back tells me you're determined. You've quit before, and I'm confident you can do it again." 1
• Avoid asking "Did you go to the meetings like we discussed?" which implies failure 1

Common Pitfalls to Avoid

• Never use confrontational statements like "Don't you see your cocaine use is hurting your family?" as this damages rapport 1
• Avoid immediately referring to addiction programs if the patient resists—first explore what they're willing to try 1
• Don't focus solely on checking compliance with previous recommendations—this misses the opportunity for motivational engagement 1
• Never prescribe beta-blockers for cocaine-related cardiovascular symptoms as they worsen coronary vasoconstriction 2, 4

Treatment Intensity Based on Severity

For hazardous use: Brief counseling with ongoing assessment 1

For substance abuse: Brief counseling, negotiate a plan, close follow-up; if abuse continues, refer for treatment 1

For substance dependence: Brief counseling plus referral for intensive treatment (Contingency Management and Community Reinforcement Approach have the strongest evidence), consider 12-step programs as adjunct, ongoing assessment and support 1, 2