This article describes shared decision-making (SDM) and recent literature supporting its use within the context of substance abuse treatment. A framework for practicing SDM and sample decision aid tools is presented.
What is Shared Decision-Making?
Shared decision-making (SDM) is defined as an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options in order to achieve informed preferences. This is in opposition to a historical model where providers have traditionally made decisions on the behalf of their patients. SDM is different than traditional approaches where providers are considered to know best and patients just defer to their expertise. Glyn Elwyn, a leading physician-researcher on shared decision-making, describes a three-step SDM model: a) introducing choice; b) describing options, often by integrating the use of patient decision support; and c) helping patients to explore preferences and to make decisions.
SDM in Substance Abuse Treatment
SDM is invaluable when there truly are treatment choices and no absolute best option. One such example occurs in substance abuse treatment. Services range from abstinence to harm reduction and treatments, but are not limited to, counseling, naltrexone, and medication-assisted treatment (MAT) (e.g., buprenorphine and methadone). Controversy about MAT to treat opioid addiction can be seen in a November 2013 New York Times article titled “Addiction Treatment with a Dark Side.”
Though barriers to practicing SDM include time constraints, a perception that patients do not prefer SDM, and opposition to asking patients about their preferred role in decision making, researchers have found that SDM reduces drug use and psychiatric severity in substance-dependent patients. Further, a Cochrane Systematic Review of decision aids found that compared to usual care, SDM improved knowledge, produced more realistic expectations, lowered decisional conflict, increased the proportion of people active in decision making, reduced the proportion of people who remained undecided, and produced greater agreement between values and choice.
Many elements of SDM are already included in the daily practices of human service providers, such as patient-centered care and strength-based approaches. As a supplement to these skills, many tools and guides exist for both providers and patients. Several examples include Opening the Door, a guide to opening difficult conversations; Questions to Ask About Medications; Using Your Voice, tips for talking with your mental health service provider; and Talk About It!, shared decision-making skills for providers and helpers. More information, including a general overview of research and practice resources on SDM, can be found in the SAMHSA publication Shared-Decision Making and Mental Health Care. Of course, with all these resources, there are options, in one can make a choice based on individual preferences. This is almost classic shared decision-making. Can you find the missing piece?
Elwyn, G., Coulter, A., Laitner, S., Walker, E., Watson P, & Thomson R. (2010). Implementing shared-decision making in the NHS. BMJ, 341:c5146. doi: 10.1136/bmj.c5146.
Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rollnick, S., Edwards, A., & Barry, M. (2012). Journal of General Internal Medicine, 27(10), 1361–1367.
Gravel, K., Legare, F. & Graham, I.D. (2006). Barriers and facilitators to implementing shared decision-making in clinical practice: A systematic review of health professional’s perceptions. Implementation Science, 9, 1:16.
Gwyn, R. (2002). Communicating Health and Illness. London: Sage Publication.
Joosten, E.A., de Jong, C.A., de Weert-van Oeane, G.H., Sensky, T., van der Staak, C.P. (2009). Shared decision-making reduces drug use and psychiatric severity in substance-dependent patients. Psychotherapy and Psychosomatics, 78(4), 245-253.
McKinstry, B. (1992). Paternalism and the doctor-patient relationship in general practice. British Journal of General Practice, 42, 340-342.
O’Connor, A.M., Stacey, D., Entwistle, V., Llewellyn-Thomas, H., Rovner, D., Holmes-Rovener, M., Tait, V., Tetroe, J., Fiset, V, & Barry, M. (2004). Decision aids for people facing health treatment or screening decisions (Cochrane Review). Volume 3. Oxford. The Cochrane Library.
Sontag, D. (2013, November). Addiction treatment with a dark side. New York Times. Retrieved from http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html
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