Discussion3

Chapter 6. Assessment of the Patient https://doi- org.ezp.waldenulibrary.org/10.1176/appi.books.9781615370030.mg06

Shelly F. Greenfield, M.D., M.P.H.Grace Hennessy, M.D.

A number of factors influence the accurate identification, assessment, and diagnosis of substance-related disorders among patients presenting for treatment. These include the clinical setting, the style of interviewing, the attitude of the clinician, and patient characteristics such as the presence of co-occurring medical and psychiatric disorders and the stage of use or abuse of the substance. The goals of assessing patients with substance-related disorders are to 1) identify the presence of a substance-related disorder, as well as signs of harmful or hazardous use so that prevention and early intervention may take place; 2) make an accurate diagnosis and relating this to any other co-occurring medical or psychiatric disorders; 3) identify barriers to treatment as well as strengths and supports; 4) assess and enhance the patient’s motivation to change; and 5) formulate and help to initiate appropriate evidence-based interventions and treatments. In this chapter, we review principles of eliciting a substance use, psychiatric, and medical history, as well as formulating an accurate diagnosis.

Eliciting the Substance Abuse History

Interviewing Style

The clinician’s attitude and style of history taking can facilitate a thorough and accurate

assessment. Patients with substance-related disorders often report that they do not discuss their

substance use openly with physicians because of their feelings of shame, discomfort, fear,

distrust, and hopelessness (Center for Substance Abuse Treatment 2004; Weiss et al. 2000a).

Obstacles to obtaining an accurate history include the patient’s defenses, such as denial,

minimization, rationalization, projection, and externalization (Schottenfeld and Pantalon 1999).

Asking open-ended questions such as “What brought you here to see me today?” may

circumvent these obstacles. Open-ended questions help the clinician understand how the patient

defines the problem, and this can set the direction for the rest of the interview.

Asking questions in an honest, respectful, and matter-of-fact manner is likely to be most

effective (Center for Substance Abuse Treatment 2004). Maintaining a nonjudgmental stance is

helpful to patients who may have feelings of shame or denial. For example, a clinician may ask,

“How were you feeling before you drank?” rather than “Why did you drink alcohol then?”

Another approach to reducing shame can be phrasing questions in such a manner as “Some

people who have alcohol problems experience blackouts. I wonder if you have ever had that

experience.” This technique can help reduce shame by conveying to the patient that there is a

range of experiences that others with similar problems have had. It also demonstrates the

clinician’s knowledge about these experiences and ability to hear the patient’s perspective.

Clinicians can also avoid using labels; instead, they can ask patients to describe their pattern of

use without labeling it. For example, if the patient says, “I’m not an addict. I just snort coke

sometimes,” the clinician can explain, “It would be helpful for me to understand the pattern of

your cocaine use, so let’s look at this past week [or other period of time].” Clinician attributes

that are effective in establishing a therapeutic alliance with patients presenting with addiction

problems include a respectful, genuine, empathic, and supportive style, as well as reflective

listening and a patient-centered approach (Center for Substance Abuse Treatment 2004; Miller

and Rollnick 2012).

Patient Characteristics

The interview can also be influenced by a number of patient characteristics that can affect the

clinical presentation of the substance-related disorder. These characteristics include 1) age,

gender, partner or marital status, legal and employment status, culture, and ethnicity; 2) level of

insight into as well as personal explanation for the nature of the problem; 3) psychiatric or

medical comorbidity; 4) stage in the course of illness (e.g., first treatment, recovery, recent

relapse); 5) current phase of use (e.g., intoxicated, withdrawing, interepisode); and 6) stage of

readiness for change.

For example, an interview with an adolescent who is dependent on marijuana may require a

different style of interviewing than an interview with an elderly widow who developed a

drinking problem in the years after her husband’s death. Women may be more likely than men to

explain their presenting problem as mood or anxiety related and may see their drinking or

substance use as a result of these difficulties and not as the primary problem (Greenfield et al.

2007). Cultural norms may differ regarding the quantity or frequency of substance use and may

affect the social acceptability and the patient’s description of his or her use (Westermeyer 2009).

A patient’s marital or partner status and employment status may also influence his or her

presentation; individuals may present for evaluation because of the urging or demands of

significant others or because of work or legal complications resulting from substance use. The

clinical presentation may also vary depending on whether the patient presents for treatment early

in the course of illness or at a more advanced phase of illness.

The current phase of drug use will also influence the clinical presentation and interview. Patients

may present in a state of intoxication, withdrawal, remission, slip, relapse, or maintenance. The

clinician is unlikely to elicit a valid history from an acutely intoxicated patient (Babor et al.

1987). If possible, an interview during intoxication may be confined to the ascertainment of

acute medical conditions in need of intervention. The complete history is best deferred to a time

when the patient is no longer intoxicated.

Clinicians may interview substance-using patients when they are requesting detoxification or

exhibiting signs and symptoms of acute withdrawal (American Psychiatric Association 2006). In

this circumstance, determining the medical need for detoxification and preventing withdrawal

complications are the most important goals of the assessment. The clinician must first assess for

signs and symptoms of withdrawal because untreated withdrawal from alcohol or sedatives,

hypnotics, or anxiolytics (e.g., benzodiazepines, barbiturates) can result in seizures, delirium

tremens, and death. Although opioid withdrawal is not associated with severe medical

complications, inpatient detoxification may be necessary to ameliorate withdrawal symptoms

that, if left untreated, could result in ongoing opioid use. Withdrawal syndromes associated with

the use of marijuana and stimulants such as cocaine and amphetamines do not require inpatient

detoxification (American Psychiatric Association 2006). Nicotine withdrawal is also managed on

an outpatient basis (American Psychiatric Association 2006).

A patient may also present in full remission from a substance-related disorder but may report

symptoms of another medical or psychiatric illness or a new onset of urges and craving. It will be

important to find out the supports the patient has used to maintain abstinence and recovery, to

examine how any other chronic or new-onset illnesses may be affecting the patient’s recovery,

and to ascertain what types of treatments or interventions may help support the patient’s ongoing

recovery. Similarly, a patient who presents with a recent slip or relapse to substance use may be

directed toward understanding the triggers to the recent drug use, as well as attempting to

identify strategies that will limit the relapse and help the patient get back on the recovery track.

The patient’s current stage of motivation for change can affect the interview (Prochaska et al.

1992). The interview with a patient who is precontemplative will usually require more probing to

elicit the history. Interview strategies that focus on establishing a pattern of use and that then

elicit advantages and disadvantages of such use may be helpful. The clinician might use a

calendar method to determine days of use in the past week, month, 3 months, 6 months, and year

(Sobell et al. 1992). For more recent time periods, the clinician can ask for patterns of use (type

of substance, quantity, frequency, time of day, etc.) for each day of the past week or month. For

more distant time periods, the questions may focus on seasonal events, such as winter holidays,

or important life events, such as birthdays. Alternatively, the clinician might ask the patient to

compare the past month’s substance use to previous 6-month time intervals to determine if

substance use has lessened or increased over time.

A similar interviewing style can be used to obtain the lifetime substance use history, with the

clinician asking for patterns of use during successive developmental periods, such as childhood,

adolescence, young adulthood, and so on. Anchoring questions to educational achievements and

other important life events (e.g., marriage, employment, military service) can also help the

clinician understand the course of substance use throughout the lifespan. After these use patterns

are identified, the patient might be encouraged to identify ways in which he or she perceives that

substance use has caused negative consequences for him or her. This interview will likely differ

from interviews with patients who have had a brief relapse after a sustained period of recovery.

Eliciting the patient’s earlier history is likely to be more straightforward and to require less

probing. These interviews are more likely to focus on the nature of the relapse, the particular

triggers to substance use, the consequences of the relapse, and the plans to help the patient return

to abstinence and recovery.

It is important to reserve time at the end of the interview to summarize what the clinician has

heard about the patient’s history, the way in which the clinician formulates this information, any

diagnostic implications that the clinician is considering, and any possible treatment options and

recommendations. The clinician may begin this part of the interview by informing the patient

that feedback about the patient’s history will be provided but then asking the patient if he or she

wants to add any information that has not been discussed or asked. After the patient has had a

chance to add any further information, the clinician can present what he or she has heard. It is

often useful to first let the patient know of any particular risk factors or vulnerabilities that he or

she may have. For example, the clinician might say, “It sounds to me as if you have a number of

risk factors. You reported that both parents had alcohol problems, and we know that this is likely

to have made you more vulnerable to the substance. Second, you reported that you have

struggled with a mood disorder, and we know that often patients with other psychiatric disorders

such as mood disorders are more vulnerable to developing drug and alcohol problems.” Then the

clinician might summarize the history the patient has given and relate the key elements of the

history to specific diagnostic criteria. This should then lead to a formulation of the diagnosis and

the treatment implications.

When the clinician is in the process of eliciting key elements of the history that will allow him or

her to formulate the diagnosis and to relate these elements back to the patient in a straightforward

manner, it is important to have in mind the diagnostic criteria and to use the interview to elicit

history that will help establish a differential diagnosis and exclude or include the likely diagnosis

for the particular patient.

Diagnosing Substance-Related Disorders

Substance-Related Disorders

In DSM-5 (American Psychiatric Association 2013), the DSM-IV-TR (American Psychiatric

Association 2000) diagnoses of substance abuse and substance dependence have been replaced

with one diagnosis, substance use disorder. Although each substance has its own substance use

disorder criteria, criteria for substance use disorders are similar across the different substances

(see Box 6–1). In general, a substance use disorder is described as a problematic pattern of

substance use leading to clinically significant impairment or distress, as manifested by at least

two symptoms occurring in a 12-month period. Current severity for substance use disorders is

described as mild if two to three symptoms are present, moderate if four to five symptoms are

present, or severe if six or more symptoms are present. The criteria for substance-related

disorders are listed in the appendix to this textbook.

DSM-5 Diagnostic Criteria for Substance Use Disorder

A. A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. 1. The substance is often taken in larger amounts or over a longer period than

was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control use.

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

4. Craving, or a strong desire or urge to use the substance. 5. Recurrent substance use resulting in a failure to fulfill major role

obligations at work, school, or home.

6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the

substance.

7. Important social, occupational, or recreational activities are given up or reduced because of substance use.

8. Recurrent substance use in situations in which it is physically hazardous. 9. Substance use is continued despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been

caused or exacerbated by the substance.

10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve

intoxication or desired effect.

b. A markedly diminished effect with continued use of the same amount of the substance.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the specific criteria sets in the appendix to this

textbook for withdrawal from the specific substances.

b. The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

 Note: Withdrawal symptoms and signs are not established for

phencyclidines, hallucinogens, and inhalants, and so this criterion

does not apply for those substances.

Specify if:

 In early remission

 In sustained remission

Specify if:

 On maintenance therapy (for opioid use disorder and tobacco use disorder only)

 In a controlled environment

Specify current severity:

 Mild: Presence of 2–3 symptoms.

 Moderate: Presence of 4–5 symptoms.

 Severe: Presence of 6 or more symptoms.

DSM-5 also provides for a number of course specifiers. In early remission is specified if none of

the substance-related disorder criteria have been met for at least 3 months but for less than 12

months. In sustained remission is specified when none of the criteria have been present for 12

months or longer. It should be noted that for these remission specifiers, the criterion “craving, or

a strong desire or urge to use” the substance, may be met. For opioid use disorder, the additional

specifier on maintenance therapy is used if the individual is taking a prescribed agonist, partial

agonist, or agonist/antagonist medication and no criteria for the opioid-related disorder have

been met for that class of medication (except tolerance to, or withdrawal from, the agonist

medication). This specifier is also used for tobacco-related disorder when long-term maintenance

medications, such as nicotine replacement therapies, are prescribed. The specifier in a controlled

environment is similarly used when the individual is in an environment where there is restricted

access to substances. Such an environment could be a locked hospital unit, a supervised

residential setting, or a substance-free prison.

Substance Intoxication and Substance Withdrawal

Substance intoxication occurs after the recent use of a substance and causes clinically significant

problematic behavioral or psychological changes that developed during or shortly after substance

use. Substance withdrawal occurs when there is a reduction in or cessation of substance use that

has been heavy or prolonged and symptoms characteristic of withdrawal from a particular

substance are experienced. Although all categories of substances except tobacco produce an

intoxication syndrome, the symptoms, signs, and durations of the syndromes vary by substance

category. On the other hand, according to DSM-5, phencyclidine and other hallucinogens, and

inhalants, do not produce a withdrawal syndrome. Knowledge of the syndromes characteristic of

each category of substances is important in eliciting an accurate history and clinical status.

Content of the Interview

Understanding the major categories of addictive substances provides the interviewer with

knowledge about their characteristic intoxication and withdrawal syndromes. This knowledge

helps the interviewer assess the patient and make appropriate treatment recommendations. It is

important to ask patients about all categories of substances and not only the primary substance.

The major categories of addictive substances are listed in Table 6–1.

History of the Substance-Related Disorder Major categories of substances of abuse

Enlarge table

A systematic and organized way of collecting information about the patient’s history of

substance use is to address the following areas: 1) age at first substance use, 2) frequency of

substance use, 3) amount of substance taken during an episode of use, 4) route of administration

for the substance, 5) consequences associated with substance use, 6) treatment history, 7) periods

of abstinence, and 8) relapses.

The information obtained by asking about the age at first substance use serves as the framework

for the history and guides the interviewer’s subsequent questions. In addition, the age when the

patient began using substances has diagnostic and prognostic implications. Early onset (before

age 15 years) of substance use is associated with the subsequent development of substance-

related disorders (Chen et al. 2005; Hingson et al. 2006).

Inquiries about the frequency of substance use as well as the amount of the substance used and

the route of administration (oral, inhaled, insufflated or snorted, intravenous, subcutaneous) help

the interviewer understand the progression of substance use over time. For example, a patient

who says she started snorting (route of administration) one bag (amount) of heroin once a week

for 1 year (frequency) and then began injecting three bags of heroin per day is reporting her

progression of heroin use in all three areas. In addition, the frequency, amount, and route of

administration of use may be related to the development of medical disorders associated with a

particular substance.

General questions about the consequences of substance use focus on changes in academic

performance, occupational functioning, and interpersonal relationships, as well as medical and

legal problems associated with substance use. The history of addiction treatment includes

questions about hospital admissions for detoxification, as well as admissions to other controlled

living situations (e.g., residential programs, halfway houses, sober houses, therapeutic

communities) to support ongoing abstinence. Outpatient programs such as partial hospital

programs, as well as group, individual, and pharmacological therapies (e.g., disulfiram,

naltrexone, buprenorphine-naloxone, methadone, nicotine replacement therapies), may also be a

part of the patient’s prior treatment. Understanding which earlier treatments did or did not help

the patient achieve and maintain abstinence can serve as a guide for treatment recommendations.

The interviewer should also ask about involvement in self-help groups (e.g., Alcoholics

Anonymous, Narcotics Anonymous, Self-Management and Recovery Training, Rational

Recovery, Women for Sobriety). Some patients may express positive or negative feelings about a

particular type of self-help group. The interviewer should not support or discredit the patient’s

feelings about self-help groups but instead should seek to understand the patient’s experiences,

both to educate the patient about the effectiveness of self-help groups and to formulate a realistic

treatment plan that will benefit the patient.

Information about a patient’s periods of abstinence as well as relapses indicates the progression

or remission of substance use, the severity of the disorder, and external factors—such as

interpersonal, psychiatric, occupational, legal or medical problems, and treatment termination—

that may have influenced the return to substance use. The interviewer should also review current

use of all substances even if no history of past use has been provided from which to ascertain

current use patterns.

Psychiatric History

There is an increased prevalence of substance-related disorders among patients diagnosed with

other psychiatric disorders (Compton et al. 2007; Kessler et al. 1997; Regier et al. 1990).

Conversely, patients diagnosed with substance-related disorders are more likely to have a co-

occurring psychiatric disorder (Brady et al. 1991; Currie et al. 2005; Mueser et al. 2000). Studies

have shown that the co-occurring substance-related and psychiatric disorders can each worsen

the prognosis for the other disorder (Greenfield et al. 1998; Hides et al. 2006; Nunes and Levin

2004). When coexisting substance-related and psychiatric disorders are diagnosed, patients can

be referred to integrated treatment for both disorders. Because evidence suggests that integrated

treatment improves and enhances outcomes for both disorders (Bennett et al. 2001; Najavits et al.

1998, 2005; Weiss et al. 2000b), it is important to assess substance-related disorders in patients

presenting for treatment of other psychiatric disorders and equally important to assess psychiatric

disorders among patients presenting for treatment of substance-related disorders.

If the patient reports symptoms consistent with a psychiatric disorder, the interviewer should

inquire about the relationship between substance use and the emergence, exacerbation, or

regression of psychiatric symptoms. A diagnosis of a substance-induced mental disorder is made

when the development of the full criteria for a mental disorder occurs during or within 1 month

of an intoxication with or withdrawal from a substance that is capable of causing the mental

disorder (American Psychiatric Association 2013). A mental disorder would be considered

independent of a substance if the disorder preceded the onset of severe intoxication or

withdrawal, or if the mental disorder persisted for a substantial period of time (e.g., at least 1

month) after substance intoxication or substance withdrawal ended. Additionally, the disorder

cannot occur exclusively during the course of a delirium and the disorder must cause clinically

significant distress or impairment in important areas of functioning. DSM-5 criteria for other

psychiatric disorders include the specifiers with onset during intoxication and with onset during

discontinuation/withdrawal. Reviewing the patient’s history of psychiatric symptoms before the

onset of substance use, during episodes of intoxication with or withdrawal from substances, and

after cessation of substance use can help the interviewer distinguish between substance-induced

mental disorders and co-occurring psychiatric and substance-related disorders.

A complete medical history—including current and past medical problems, surgical procedures,

and medication allergies—is necessary for patients presenting for assessment of a substance-

related disorder. Medical problems require treatment regardless of their relationship to substance

use, and the interviewing clinician should make treatment recommendations or referrals for

further evaluation for any conditions. In addition, patients with substance-related disorders have

often neglected their health and routine medical care and are at risk for a number of co-occurring

medical disorders. The clinician should ask about the dates of the last complete physical

examination and follow-ups for any medical problems, past or current. For each medical

condition, the interviewer should try to determine whether the symptoms are related to or

independent of substance use. Questions about a reported medical problem should include

inquiries about the temporal relationship between the development of the medical condition and

substance use. It is also important to ask about current and past medical problems that are

specific to use of a particular substance. A description of all the medical problems associated

with each category of substances is beyond the scope of this chapter; the major medical problems

and disorders associated with the more commonly abused substances are listed in Table 6–2.

Medical History Medical problems associated with substance-related disorders

Enlarge table

Obtaining a reproductive health history is important in the evaluation of women with substance-

related disorders. Relevant history among women of childbearing age includes a menstrual

history and determining whether the patient is or may be pregnant. Women who know they are

pregnant may want additional information on risk of substance use. A pregnancy test can be

offered if a pregnancy is in question. Pregnancy can serve as a powerful motivator for cessation

of substance use, and pregnant women may wish to seek substance abuse treatment that has

specialized services (Brady and Ashley 2005). During different phases of the menstrual cycle,

women can experience changes in craving and substance use, as well as differences in likelihood

of stopping their substance use (Greenfield et al. 2011). Changes in sleep or symptoms such as

hot flashes may be relevant factors in the use of substances for perimenopausal and

postmenopausal women.

Lastly, understanding the relationship between the development and exacerbation of the patient’s

medical disorders and the patient’s substance use provides the interviewer with information that

may motivate the patient to change addictive behavior. The medical history will also provide the

information necessary to refer the patient to appropriate medical care regardless of the origin of

the medical disorder.

Family History

The family history of substance-related disorders may reveal a genetic vulnerability to the

patient’s own development of these disorders (Agrawal and Lynskey 2008). The environment

created by families with substance-related disorders may also have an impact on the

development of substance-related disorders in their children. Interviewers can educate patients

about genetic vulnerability and family environmental factors associated with substance-related

disorders. This information may provide patients with an understanding of their current problems

with substances as well as compelling reasons why they should refrain from substance use.

Social and Developmental History

Important psychosocial factors to explore include the patient’s relationships with others, the

influence of these relationships on both initiation and continued use of substances, and the

existence of any supportive relationships that help the patient abstain from substances or stop

using substances after starting. Childhood physical or sexual abuse (Nelson et al. 2006) is a risk

factor for the development of substance-related disorders as well as for poorer drinking outcomes

(Greenfield et al. 2002) and psychiatric outcomes (Pirard et al. 2005). Developing meaningful

interpersonal relationships, however, can help patients build a social network that supports

recovery (Havassy et al. 1991). The presence or absence of a spouse or partner can have an

important influence on the development and perpetuation of a substance-related disorder (Hser et

al. 1987) and may also have positive or negative effects on treatment outcomes (Walitzer and

Dearing 2006). Educational attainment and employment can be affected by substance use.

Substance use may lead to school absenteeism, poor school performance, and dropout (Lynskey

and Hall 2000; Lynskey et al. 2003); lower educational status (Crum et al. 1998); and lower

income (Mullahy and Sindelar 1989).

Physical and mental status examinations of patients presenting for an assessment of a substance-

related disorder are critical parts of the evaluation because both medical and psychiatric

disorders are commonly found in this population. Although a mental status examination can and

must be performed regardless of the treatment setting, the interviewer may be unable to perform

a physical examination due to lack of appropriate space, equipment, and training. Patient factors

such as refusal to undergo an examination or inability to cooperate with the examination due to

substance intoxication or withdrawal may also be reasons to defer the physical examination.

Under such circumstances, the interviewer should refer the patient to the appropriate person

(e.g., primary care physician) or facility (e.g., emergency room) for a complete physical

examination.

Specific signs of substance use that may present during the physical or mental status examination

will depend on the type of substance used and the presence of intoxication with or withdrawal

from substances (Washburn 2002). The signs and symptoms of substance intoxication and

withdrawal, according to DSM-5, are listed in Tables 6–3 and 6–4, respectively.

Physical and Mental Status Examinations DSM-5 signs and symptoms of substance intoxication

Enlarge table

Physical and Mental Status Examinations DSM-5 signs and symptoms of substance withdrawal

Enlarge table

Although many physical signs of substance use are easily observed when the interviewer

performs the mental status examination, other signs of substance use are best detected by

performing a thorough physical examination. For example, a patient with hepatic damage as a

result of chronic alcohol use or hepatitis infection resulting from intravenous drug use may

present with a slightly enlarged liver or, in more advanced cases of hepatic damage, jaundice,

abdominal distention secondary to ascites, gynecomastia, spider angiomas, palmar erythema, and

caput medusa. A complete description of all the physical findings associated with substance use

is beyond the scope of this chapter; this example is presented to illustrate the importance of a

thorough physical examination to detect other signs of substance-related medical disorders that

require immediate treatment.

The physical and mental status examinations of a patient presenting for an evaluation of a

substance-related disorder can be dramatically affected by states of intoxication or withdrawal.

Alterations in mood, affect, psychiatric symptoms, thought processes, thought content, speech,

memory, orientation, cognition, insight, and judgment are commonly seen when patients are

intoxicated with or are withdrawing from a particular substance. Similarly, substance

intoxication or withdrawal can lead to significant changes in the patient’s physiological state,

including abnormalities in blood pressure, body temperature, and level of consciousness, as well

as disruption in the stability and functioning of major organ systems such as the neurological and

gastrointestinal systems. In addition, the mental status examination provides important

information for the diagnosis of other psychiatric disorders and for the evaluation of the current

remission, recurrence, or stability of any other concurrent psychiatric disorder. A comparison of

the patient’s physical and mental status examinations during different stages of substance abuse

treatment is one way to evaluate changes in substance use and in any concurrent medical and

psychiatric disorders.

Obtaining Additional Information

A patient’s significant others can often serve as collateral informants who can corroborate and provide additional information about the patient’s reported substance use history (Carroll 1995). Speaking with the patient’s significant others also allows for their early involvement in treatment planning and may help in establishing social networks that can potentially support the patient’s recovery and help maintain abstinence (Havassy et al. 1991). Contact with collateral informants should occur only with written permission from the patient.

Biological markers can help in detecting the degree and regularity of the patient’s substance use (Kolodziej et al. 2002) and may be useful in spite of the limitations of each specific test. These tests include breath alcohol testing, quantitative urine or serum drug screens, and serum tests for blood markers of hepatic dysfunction or hematological problems. Finally, a number of standardized instruments exist for screening, diagnostic assessment, and evaluation of severity and may be helpful in the overall assessment of the patient (Knight et al. 2003).

Conclusion

In this chapter we have discussed the importance of assessing substance use in all patients seen in the clinical setting. We have outlined the content areas of inquiry of the interview as well as the adjunctive use of the physical examination and mental status examination. A careful and accurate assessment of the patient will provide the necessary information for intervention and treatment planning and will increase motivation by beginning to engage the patient in the process of change.

Key Points

1. Successful treatment of substance-related disorders depends on a careful, accurate assessment and diagnosis.

2. Accurate assessment is facilitated by interview settings that provide privacy and patient confidentiality and that permit adequate time to ask key questions, to follow up on positive patient responses, and to give feedback to the patient.

3. A substance use history should be obtained from all patients presenting for treatment.

4. Patient assessment can be influenced by a number of patient characteristics, including the patient’s age, gender, ethnicity, and legal, marital, and employment status; degree of insight into the nature of the problem; medical or psychiatric comorbidity; stage in the course of illness (e.g., recovery, recent relapse, first treatment); current phase of use (e.g., intoxication, withdrawal, interepisode); and stage of readiness for change and motivation.

5. A complete substance use assessment requires eliciting the history of use for all the major categories of substances, with a focus on age at first use, frequency and amount of use, consequences of use, substance abuse treatment history, and complete psychiatric, medical and social, and developmental histories.

6. Collateral informant interviews, standardized questionnaires, and biological testing may also provide additional helpful information for some patients.

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Suggested Readings

1. Brady KT, Back SE, Greenfield SF (eds): Women and Addiction: A Comprehensive Handbook. New York, Guilford, 2009

2. Connors GJ, Donnovan DM, Diclemente CC: Substance Abuse Treatment and Stages of Change. New York, Guilford, 2001

3. Cummings NA, Cummings JL: The First Session With Substance Abusers: A Step-by-Step Guide. New York, Wiley, 2000

4. Miller WR, Rollnick S: Motivational Interviewing: Preparing People for Change, 3rd Edition. New York, Guilford, 2012

5. Stevens LH, Dennis ML: Clinical assessment, in Substance Abuse: A Comprehensive Assessment. Edited by Ruiz Pm, Strain E. Philadelphia, PA, Lippincott, Williams & Wilkins, 2011, pp 107–116