Delivering Substance Use Messages That Pack a Punch
A New Paradigm
I had good intentions and the right message. I’d wanted Sarah—a 20-something with alcohol issues—to open up about what was going on. But my delivery was off, and I’d said it wrong, so instead, she closed off. She clutched her arms to her chest and gazed frozenly at a spot in the distance, looking even more miserable than she had before.
We’ve all been there. We have a really compelling point to be made, but somehow it doesn’t get through. Conversations about substance use, like those about any other desired health behavior change, are a form of persuasion. So how can we best persuade others to make important, life-saving choices? What can we do to actually make substance use prevention, treatment, and recovery messages successful?
It’s not only what we say that matters but how we say it. In fact, how messages are delivered—from who should be delivering them to when and how they should be delivered—may be even more important than what’s being said. Whether the goal is prevention or to inspire treatment seeking, we often spend too much time on content and not enough on logistics. Even the best argument can get lost when it’s presented in a way that does not resonate or, worse—that alienates.
Luckily there are a number of tried-and-true delivery techniques that have been shown to be effective across the substance use disorder (SUD) continuum—from prevention, to treatment, to recovery. Substance use is a nonlinear progression that often ebbs and flows throughout the lifespan and so is best addressed continuously with care that spans disease progression, or lack thereof. Given this need for nonstage-specific approaches to care, I have recently proposed the new paradigm of continuum capital. This refers to the resources needed to avoid, moderate, or recover from substance use challenges and to maintain a state of well-being, denoting the shared strengths that we need to build in individuals throughout their lifespan, regardless of what stage they are in on their substance use journeys. Too often, specific substance use stages are treated and funded as completely separate conditions when there are actually more similarities between effective interventions in prevention and recovery than not.
Keeping that in mind, we can use this paradigm to identify the delivery methods—the who, what, where, why, when, and how—that are most effective at motivating and inspiring resilience and change across the many stages of substance use.
Who Is Speaking? Lived Experience
Victor Sauceda, a community fellow for Code for America, puts it simply in his article “Power of Lived Experience” on the organization’s website, saying, “Lived experience means that a person has lived through the problem that is going to be solved. People who have been closest to the problem have the most experience with it, can elevate real concerns, devise the most pointed solutions, and engage community support.”
In both treatment and recovery, the peer recovery coach model allows those in recovery to connect and guide those in active addiction. The lived experience that peer specialists bring has been so successful that the model has quickly become a cornerstone of all addiction services. Peer recovery coaches have proven effective in improving long-term SUD treatment outcomes and higher treatment adherence rates.1 Two rigorous systematic reviews that examined the body of published research on the effectiveness of peer-delivered recovery supports published from 1995 to 2014 found that there is a positive impact on patients.2,3
This popular delivery system can also be applied across the substance use continuum to areas where lived experience has been less utilized. Despite the common misconception that lived experience is only effective in treatment and recovery, research has indicated otherwise. Youth survey research spanning more than 2,000 participants revealed that 68% said that an individual with lived experience would be among the most trusted messengers for the delivery of substance use prevention messages.4
Even if you don’t personally have ample experience with severe SUD, almost everyone has been exposed to some form of substance use prevention and knows someone who may have struggled. There are authentic ways to bring in our own personal experiences that can be woven throughout our substance use conversations.
What Is Unsaid? Trust, Rapport, and the Nature of the Relationship
Trust and rapport are the unsaid requirements for productive conversations. Self-determination theory posits that relatedness (eg, close personal relationships, trust, rapport) is a precursor to behavioral change, and research supports its importance to the individual motivation that leads to positive addiction treatment outcomes.6,7
Patients feel heard and understood when we listen more than talk and ask permission before sharing information. Body language can often signal whether the patient feels comfortable.
In a 2022 needs assessment of more 600 youth across the United States, the survey found a distinction between the sources youth cited as the most trusted for information vs the most trusted source for actual substance use prevention conversations.4
Building this type of foundation takes time but is critical to discussions around sensitive health topics such as substance use and mental health. Therapeutic rapport relies on an unspoken approach that builds empathy and shared understanding.
Where Are You Speaking? Safe Spaces
Whether in prevention or recovery, confidentiality is the true foundation of safe spaces and highlights what is the cornerstone of the therapist-patient relationship. But we see confidentiality outside of the therapeutic relationship as well. In Alcoholics Anonymous, for example, the word anonymous is not only in the name but individuals in Alcoholics Anonymous also only share their first names in meetings. In the prevention realm, youth report that they go online as one of their primary sources for substance use information, and youth cite wanting places where they can go to ask anonymous questions where they don’t fear “getting in trouble.”4
Beyond confidentiality, emotional safety can also be strengthened by checking our own biases to create a judgment free space, providing trauma-informed care, using inclusive language, and approaching conversations with a sense of cultural humility, where we ask about individual patient preferences instead of assuming. These techniques allow patients to show up as they are, whether curious or in fear, and entail making efforts to meet the patient where they are along the substance use continuum.
In a needs assessment conducted by the National Council for Mental Wellbeing, youth expressed many different reasons for choosing not to engage in substance use, from not wanting to mess up future plans or current hobbies to the risk of addiction and strength in relationships. Framing communication and customizing messages around the things that matter most to the individual makes the information more pertinent.4
We see similar benefits in personalizing treatment and recovery: It maximizes feelings of control and ownership in the recovery journey. Listening for the individual’s unique primary reasons for substance use can be helpful in planning and matching treatment with the patient.8
When Are You Speaking? Timing
Timing is everything, and so is consistency. The earlier that youth initiate substance use, the higher their risk for development of SUD, so we need to get in front of them sooner. Early, regular messaging can set youth up for healthful behaviors, and as we have seen in other bodies of research, the likelihood of success is substantially increased by multiple touch points. Prevention research shows that the benefits from middle-school prevention programs diminish without follow-up programs in high school.9,10
Substance use prevention education and communication need to be delivered continuously throughout the human lifespan: it is not just an issue for youth. Older adults are also at risk for first-time or recurrent substance use challenges. One million adults aged 65 and older in the United States have an SUD, and that number is likely underreported due to stigma and misdiagnosis.11 In fact, while it’s true that two-thirds of older adults with an SUD began using substances before the age of 22, one-third of older adults developed SUD later in life.12
The importance of timing and consistency holds true for substance use treatment and recovery. Once substance use and dependency have already begun, early intervention decreases the severity of SUDs and reduces health-related consequences of substance use. It also decreases the likelihood of death. Consistency is also key to recovery. We can’t send individuals to a 30-day rehab and expect full abstinence moving forward. Recovery is a long road that requires constant communication to inspire, support, and help rebuild lives. Remission from SUD—the point at which the individual is no more likely than anyone else in the general population to develop an SUD again—is marked at five years. Research on alcohol use disorder has found that continuing care programs that regularly deliver care over time result in improvements in alcohol consumption, alcohol-related impairment, and abstinence rates, among other factors.13,14
How Are You Speaking?
In the prevention realm, listening to youth helps build strong relationships that protect against engagement in risky behavior such as substance use, while in treatment and recovery, shared decision-making and listening help to develop the working relationships that facilitate treatment retention and improved patient engagement.
Conversational skills across the continuum of care for substance use are often informed by motivational interviewing models, where the delivery of the message is the main focus.15 Using simple techniques such as reflective listening and asking open-ended questions that patients can’t answer with a single word response are used to facilitate impactful conversations around substance use.
As I learned very early on when talking to Sarah about her substance use challenges, if you don’t fully nail the who, what, where, when, why, and how of your approach, your substance use conversations will be ill-fated. Our communication on sensitive health topics is more than just the words that we say: It is our framing and context that allows what we say to be influential.
Now more than ever, we need to deliver substance use messages that work across all stages of substance use progression. This means employing reliable techniques: pulling from lived experience, building trust and rapport, focusing on partnership, personalizing messages to the individual, and having substance use conversations early and often. Given the acute consequences of substance use, we need to hone our message delivery across the continuum to give evidence-based messages and interventions the best chance of success and to ultimately save lives.
— Alexandra Plante is a director at the National Council for Mental Wellbeing, specializing in substance use disorder initiatives, and works alongside the United Nations Office of Drug Control and Crime on unethical practices in substance use disorder treatment and recovery. Previously, she’s been a consultant to US federal agencies and state policymakers, international agencies, and private entities such as Google. Her writing has been featured in outlets such as Scientific American, Harvard Health Publications, and Psychology Today. She previously was a director at the Massachusetts General Hospital and Harvard Medical School - Recovery Research Institute and DynamiCare Health. She’s on LinkedIn at www.linkedin.com/in/alexandra-plante.
2. Bassuk EL, Hanson J, Greene RN, Richard M, Laudet A. Peer-delivered recovery support services for addictions in the United States: a systematic review. J Subst Abuse Treat. 2016;63:1-9.
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