Substance Use Assessment

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Substance Use AssessmentSubstance Use Assessment

Chapter 6Chapter 6


Chapter 6: Substance Use AssessmentChapter 6: Substance Use Assessment

Alcohol Use and AbuseAlcohol Use and Abuse

AlcoholAlcohol Most used and abused psychoactive drugMost used and abused psychoactive drug Given rates of alcohol use, it is not surprising that Given rates of alcohol use, it is not surprising that

many patients in hospital and primary care find many patients in hospital and primary care find themselves with alcohol-related disordersthemselves with alcohol-related disorders

Morbidity and mortality data reflect adverse Morbidity and mortality data reflect adverse consequences of excessive alcohol useconsequences of excessive alcohol use• Alcohol is involved in 40% of 41,000 annual deaths due Alcohol is involved in 40% of 41,000 annual deaths due

to traffic accidentsto traffic accidents

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Alcohol Use and AbuseAlcohol Use and Abuse (cont.)(cont.)

Alcohol (cont.)Alcohol (cont.) Emergency department visits attributable to Emergency department visits attributable to

alcohol from 1992 to 2000 was about 68.6 million, alcohol from 1992 to 2000 was about 68.6 million, with an increasing trend of 18%with an increasing trend of 18%• Alcohol consumption of four standard drinks per day or Alcohol consumption of four standard drinks per day or

more associated with increased rates of death in men more associated with increased rates of death in men from:from:

Cirrhosis and alcoholismCirrhosis and alcoholism Cancers of mouth, esophagus, pharynx, and liver Cancers of mouth, esophagus, pharynx, and liver

combinedcombined Injuries and other external causesInjuries and other external causes

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Alcohol (cont.)Alcohol (cont.) In women, alcohol consumption increases risk of In women, alcohol consumption increases risk of

breast cancer in a dose-response relation, starting breast cancer in a dose-response relation, starting at an alcohol intake of about two drinks per dayat an alcohol intake of about two drinks per day

Link between chronic alcohol use and liver Link between chronic alcohol use and liver disease is well knowndisease is well known

Chronic heavy use increases risk of alcoholic Chronic heavy use increases risk of alcoholic cardiomyopathy, with an increase in left ventricular cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinningmass, dilation of ventricles, and wall thinning

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Alcohol (cont.)Alcohol (cont.) Hypertension is a common detrimental effectHypertension is a common detrimental effect Because of alcohol related morbidity, many Because of alcohol related morbidity, many

patients encountered in primary care settings and patients encountered in primary care settings and in hospital will have significant drinking historyin hospital will have significant drinking history

Alcohol dependence increases risk of sepsis, Alcohol dependence increases risk of sepsis, septic shock, and hospital mortality among septic shock, and hospital mortality among intensive care unit (ICU) patients intensive care unit (ICU) patients

Excessive alcohol use increases risk for ICU Excessive alcohol use increases risk for ICU admissions due to trauma, hypothermia, and admissions due to trauma, hypothermia, and pancreatitispancreatitis

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Defining Illicit Drug UseDefining Illicit Drug Use

About 8% of Americans aged 12 or older About 8% of Americans aged 12 or older reported current illicit drug use in 2008reported current illicit drug use in 2008 Illicit drugs include marijuana/hashish, cocaine Illicit drugs include marijuana/hashish, cocaine

(including crack), heroin, hallucinogens, inhalants, (including crack), heroin, hallucinogens, inhalants, or prescription-type drugs used nonmedicallyor prescription-type drugs used nonmedically• Marijuana was most commonly used illicit drug with 6.1% Marijuana was most commonly used illicit drug with 6.1%

of persons aged 12 or older reporting past month useof persons aged 12 or older reporting past month use

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Defining Illicit Drug UseDefining Illicit Drug Use (cont.)(cont.)

Illicit drug use has serious consequences for Illicit drug use has serious consequences for health, relationships, and for future jobs, health, relationships, and for future jobs, school and careerschool and career Abuse of prescription drugs is fastest growing drug Abuse of prescription drugs is fastest growing drug

problem in U.S. problem in U.S. Three most frequently abused prescription opioid Three most frequently abused prescription opioid

pain relievers were products using: pain relievers were products using: • Oxycodone Oxycodone

• HydrocodoneHydrocodone

• MethadoneMethadone

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Diagnosing Substance AbuseDiagnosing Substance Abuse

Rate of Americans classified with substance Rate of Americans classified with substance abuse or dependence abuse or dependence 9.2 % of the population aged 12 or older9.2 % of the population aged 12 or older 68% of those were dependent on or abused 68% of those were dependent on or abused

alcohol but not illicit drugs, and 14% used both alcohol but not illicit drugs, and 14% used both alcohol and illicit drugsalcohol and illicit drugs

Alcohol dependence or alcoholism is a chronic Alcohol dependence or alcoholism is a chronic progressive disease that is not curable but is progressive disease that is not curable but is highly treatablehighly treatable

Accurate diagnosis needed for advice, Accurate diagnosis needed for advice, intervention, appropriate treatment, and follow-upintervention, appropriate treatment, and follow-up

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Diagnosing Substance AbuseDiagnosing Substance Abuse (cont.)(cont.)

Gold standard of diagnosis is well defined in Gold standard of diagnosis is well defined in Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)Disorders (DSM-IV) Alcohol problems under-diagnosed both in primary Alcohol problems under-diagnosed both in primary

care settings and in hospitalscare settings and in hospitals Excessive alcohol use often unrecognized until Excessive alcohol use often unrecognized until

patients develop serious complicationspatients develop serious complications

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Developmental CompetenceDevelopmental Competence

Pregnant womanPregnant woman Among pregnant women 15 to 44Among pregnant women 15 to 44

• About 10.6% report current alcohol useAbout 10.6% report current alcohol use

• 4.5% reporting binge drinking and 4.5% reporting binge drinking and

• 0.8% reporting heavy drinking0.8% reporting heavy drinking

• No amount of alcohol has been determined safe for No amount of alcohol has been determined safe for pregnant womenpregnant women

• Potential adverse consequences of alcohol use to fetus Potential adverse consequences of alcohol use to fetus are well knownare well known

• All women who are contemplating pregnancy or who are All women who are contemplating pregnancy or who are pregnant should be screened for alcohol use, and pregnant should be screened for alcohol use, and abstinence should be recommendedabstinence should be recommended

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Developmental CompetenceDevelopmental Competence (cont.)(cont.)

Aging adultAging adult Prevalence of current alcohol use decreases with Prevalence of current alcohol use decreases with

increasing ageincreasing age• 67.4% among those 26 to 2967.4% among those 26 to 29

• 50.3% among those 60 to 6450.3% among those 60 to 64

• 39.7% among those 65 or older39.7% among those 65 or older

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Developmental CompetenceDevelopmental Competence (cont.)(cont.)

Aging adult (cont.)Aging adult (cont.) Older adults have numerous characteristics that Older adults have numerous characteristics that

increase risk of alcohol useincrease risk of alcohol use• Liver metabolism and kidney functioning decreases, Liver metabolism and kidney functioning decreases,

increase availability of alcohol in blood for longer periodsincrease availability of alcohol in blood for longer periods

• Less tissue mass means increased alcohol concentration Less tissue mass means increased alcohol concentration in bloodin blood

• Older adults on multiple medications that can interact Older adults on multiple medications that can interact adversely with alcohol, including benzodiazepines, adversely with alcohol, including benzodiazepines, antidepressants, antihypertensives, and aspirinantidepressants, antihypertensives, and aspirin

• Drinking alcohol increases risk of falls, depression, and Drinking alcohol increases risk of falls, depression, and gastrointestinal problemsgastrointestinal problems

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Subjective DataSubjective Data

If patient is currently intoxicated or going If patient is currently intoxicated or going through substance withdrawal, collecting any through substance withdrawal, collecting any history data is difficult and unreliablehistory data is difficult and unreliable However, when sober, most people are willing and However, when sober, most people are willing and

able to give reliable data, provided that setting is able to give reliable data, provided that setting is private, confidential, and nonconfrontationalprivate, confidential, and nonconfrontational

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Subjective DataSubjective Data (cont.)(cont.)

Alcohol useAlcohol use Ask about alcohol useAsk about alcohol use

• Do you sometimes drink beer, wine, or other alcoholic Do you sometimes drink beer, wine, or other alcoholic beverages?beverages?

If answer is “Yes,” then ask screening question If answer is “Yes,” then ask screening question about heavy drinking days, such as, “How many about heavy drinking days, such as, “How many times in past year have you had five or more times in past year have you had five or more drinks a day (for men) or four or more drinks a day drinks a day (for men) or four or more drinks a day (for women)?”(for women)?”

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Alcohol use (cont.)Alcohol use (cont.) To complete a picture of person’s drinking pattern, To complete a picture of person’s drinking pattern,

ask, “On average, how many days a week do you ask, “On average, how many days a week do you have an alcoholic drink?” and “On a typical drinking have an alcoholic drink?” and “On a typical drinking day, how many drinks do you have?” day, how many drinks do you have?”

Recommend person stay at moderate drinking Recommend person stay at moderate drinking patternspatterns

Recommend even lower limits or abstinence for Recommend even lower limits or abstinence for patients who take medications that interact with patients who take medications that interact with alcohol, who have a health condition exacerbated by alcohol, who have a health condition exacerbated by alcohol, or who are pregnant (advise abstinence alcohol, or who are pregnant (advise abstinence here)here)

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Alcohol use (cont.)Alcohol use (cont.) Use brief screening instruments to help identify Use brief screening instruments to help identify

problem drinking and those who need more problem drinking and those who need more thorough assessmentthorough assessment

AUDIT questionnaireAUDIT questionnaire• A quantitative form that has the advantage of letting the A quantitative form that has the advantage of letting the

examiner document a number for a response so it is not examiner document a number for a response so it is not open to individual interpretationopen to individual interpretation

• The AUDIT will help detect less severe alcohol problems The AUDIT will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol (hazardous and harmful drinking) as well as alcohol abuse and dependence disordersabuse and dependence disorders

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Alcohol use (cont.)Alcohol use (cont.) AUDIT questionnaire (cont.)AUDIT questionnaire (cont.)

• Helpful with emergency department (ED) and trauma patients Helpful with emergency department (ED) and trauma patients because it is sensitive to current, as opposed to past alcohol because it is sensitive to current, as opposed to past alcohol problemsproblems

• Useful in primary care with adolescents and older adultsUseful in primary care with adolescents and older adults

• Relatively free of gender and cultural bias Relatively free of gender and cultural bias

Note that AUDIT covers three domains Note that AUDIT covers three domains • Alcohol consumptionAlcohol consumption

• Drinking behavior or dependenceDrinking behavior or dependence

• Adverse consequences from alcoholAdverse consequences from alcohol The AUDIT-C is shorter form helpful for acute and critical care The AUDIT-C is shorter form helpful for acute and critical care

unitsunits

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Alcohol use (cont.)Alcohol use (cont.) The CAGE questionnaire (Cutdown, Annoyed, The CAGE questionnaire (Cutdown, Annoyed,

Guilty, Eye opener) Guilty, Eye opener) • Works well in primary care settings because it takes less Works well in primary care settings because it takes less

than 1 minute to completethan 1 minute to complete

• The CAGE tests for lifetime alcohol abuse and/or The CAGE tests for lifetime alcohol abuse and/or dependence dependence

Does not clarify past problem drinking from presentDoes not clarify past problem drinking from present Less effective with women and minority groupsLess effective with women and minority groups

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Alcohol use (cont.)Alcohol use (cont.) Assess for alcohol use disorders using standard Assess for alcohol use disorders using standard

clinical diagnostic criteriaclinical diagnostic criteria Determine whether there is a maladaptive pattern Determine whether there is a maladaptive pattern

of alcohol use causing clinically significant of alcohol use causing clinically significant impairment or distress impairment or distress

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Alcohol use (cont.)Alcohol use (cont.) Ask, “In past 12 months, has your drinking Ask, “In past 12 months, has your drinking

repeatedly caused or contributed to:repeatedly caused or contributed to:• Risk of bodily harm: drinking and driving, operating Risk of bodily harm: drinking and driving, operating

machinery, swimming?machinery, swimming?

• Relationship trouble: family or friends?Relationship trouble: family or friends?

• Role failure: interference with home, work, or school Role failure: interference with home, work, or school obligations?obligations?

• Run-ins with law: arrests or other legal problems?”Run-ins with law: arrests or other legal problems?”

Ask, “In the past 12 months, have you not been Ask, “In the past 12 months, have you not been able to stick to drinking limits, or repeatedly gone able to stick to drinking limits, or repeatedly gone over them?”over them?”

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Alcohol use (cont.)Alcohol use (cont.) Ask, “In past 12 months, has your drinking Ask, “In past 12 months, has your drinking

repeatedly caused or contributed to:repeatedly caused or contributed to:• Shown tolerance: needed to drink more to get same Shown tolerance: needed to drink more to get same

effect?effect?

• Shown signs of withdrawal: tremors, sweating, nausea, Shown signs of withdrawal: tremors, sweating, nausea, or insomnia when trying to quit or cut down?or insomnia when trying to quit or cut down?

• Kept drinking despite problems: recurrent physical or Kept drinking despite problems: recurrent physical or psychological problems?psychological problems?

• Spent a lot of time drinking or anticipating or recovering?Spent a lot of time drinking or anticipating or recovering?

• Spent less time on other matters or activities that had Spent less time on other matters or activities that had been important or pleasurable?”been important or pleasurable?”

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Alcohol use (cont.)Alcohol use (cont.) Ask about use of illicit substancesAsk about use of illicit substances

• ““Do you sometimes take illicit drugs or street drugs, such Do you sometimes take illicit drugs or street drugs, such as marijuana, cocaine, hallucinogens, narcotics?”as marijuana, cocaine, hallucinogens, narcotics?”

• If yes, ask, “When was last time you used drugs, and If yes, ask, “When was last time you used drugs, and how much did you take that time?”how much did you take that time?”

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Screening women for alcohol problemsScreening women for alcohol problems The TWEAK questions help identify at-risk The TWEAK questions help identify at-risk

drinking in women, especially pregnant womendrinking in women, especially pregnant women• TTolerance: how many drinks can you hold? Or How olerance: how many drinks can you hold? Or How

many drinks does it take to make you feel high? many drinks does it take to make you feel high?

• WWorry: have close friends or relatives complained about orry: have close friends or relatives complained about your drinking?your drinking?

• EEye-opener: do you sometimes take a drink in morning ye-opener: do you sometimes take a drink in morning when you first get up?when you first get up?

• AAmnesia: has a friend or family member told you about mnesia: has a friend or family member told you about things you said but could not remember?things you said but could not remember?

• KKut down: do you sometimes feel need to cut down?ut down: do you sometimes feel need to cut down?

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Screening aging adultsScreening aging adults Use the SMAST-G questionnaire for older adults Use the SMAST-G questionnaire for older adults

who report social or regular drinking of any who report social or regular drinking of any amount of alcohol amount of alcohol

Older adults have specific emotional responses Older adults have specific emotional responses and physical reactions to alcohol and the 10 and physical reactions to alcohol and the 10 questions with yes/no responses address these questions with yes/no responses address these factorsfactors

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Advise and assist, brief interventionAdvise and assist, brief intervention Consequences of substance abuse are so Consequences of substance abuse are so

debilitating and destructive to patients and their debilitating and destructive to patients and their families that a short statement of assistance and families that a short statement of assistance and concern is given hereconcern is given here

If your assessment has determined the patient to If your assessment has determined the patient to have at-risk drinking or illicit substance use, state have at-risk drinking or illicit substance use, state your conclusion and recommendation clearlyyour conclusion and recommendation clearly• ““You are drinking more than is medically safe.” You are drinking more than is medically safe.”

• Relate to the person’s concerns and medical findings, if Relate to the person’s concerns and medical findings, if present; “I strongly recommend that you cut down, or present; “I strongly recommend that you cut down, or quit, and I’m willing to help.”quit, and I’m willing to help.”

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Advise and assist, brief intervention (cont.)Advise and assist, brief intervention (cont.) If you determine the person has an alcohol use If you determine the person has an alcohol use

disorder, state your conclusion and disorder, state your conclusion and recommendation clearlyrecommendation clearly• ““I believe that you have an alcohol use disorder.”I believe that you have an alcohol use disorder.”

• ““I strongly recommend that you quit drinking, and I’m I strongly recommend that you quit drinking, and I’m willing to help.”willing to help.”

Relate to the person’s concerns and medical findings, if Relate to the person’s concerns and medical findings, if presentpresent

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Objective DataObjective Data

Clinical laboratory findings give objective Clinical laboratory findings give objective evidence of problem drinkingevidence of problem drinking These are less sensitive and specific than self-These are less sensitive and specific than self-

report questionnairesreport questionnaires• Useful data to corroborate subjective dataUseful data to corroborate subjective data

• Serum protein, gamma glutamyl transferase (GGT) is Serum protein, gamma glutamyl transferase (GGT) is most commonly used biochemical marker of alcohol most commonly used biochemical marker of alcohol drinkingdrinking

• Occasional alcohol drinking will not raise this measure, Occasional alcohol drinking will not raise this measure, but chronic heavy drinking willbut chronic heavy drinking will

Be aware that nonalcoholic liver disease also can increase Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcoholGGT levels in the absence of alcohol

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Objective DataObjective Data (cont.)(cont.)

Clinical laboratory findings give objective Clinical laboratory findings give objective evidence of problem drinking (cont.)evidence of problem drinking (cont.)

• From complete blood count, the mean corpuscular From complete blood count, the mean corpuscular volume (MCV) is an index of red blood cell sizevolume (MCV) is an index of red blood cell size

MCV is not sensitive enough to use as only biomarkerMCV is not sensitive enough to use as only biomarker– Can detect earlier drinking after long period of abstinenceCan detect earlier drinking after long period of abstinence

• Breath alcohol analysis detects any amount of alcohol in Breath alcohol analysis detects any amount of alcohol in end of exhaled air following a deep inhalation until all end of exhaled air following a deep inhalation until all ingested alcohol is metabolizedingested alcohol is metabolized

• This measure can be correlated with blood alcohol This measure can be correlated with blood alcohol concentration (BAC) and is basis for legal interpretation concentration (BAC) and is basis for legal interpretation of drinkingof drinking

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Substance Use Assessment

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