Quick Reference for Substance-Related Disorders
Substance abuse interview
Need to determine:
Progression
Evidence of escalating use (frequency), tolerance (how many drinks before intoxicated), habituation, or physiologic dependence (presence of withdrawal signs or symptoms when abstaining)
Impaired control
Attempts to cut back on use or abstain; remorse after use; consumption of more alcohol or drug than intended on more than one occasion; setting up conditions to attempt to limit use (e.g., “I’m only drinking beer” or “I’m only using on weekends”)
Preoccupation with use
Cravings or a subjective sense of compulsion to use; planning social occasions to use
Adverse life consequences
As a result of substance abuse, loss of or damage to health (including mental health—depression that doesn’t seem to get better); loss of or damage to family relationships, social relationships; damage to education or career, finances, or religious practice; family or employer concerns; or legal problems related to use (divorce, loss of child custody, driving under the influence, public intoxication, domestic abuse)
Denial
Minimization of use, justification or rationalization of use, inability to acknowledge the consequences of use, euphoric recall (i.e., remembering only the pleasant aspects of abusing a substance), suppression or repression of painful affect, enabling behaviors among social support network, cognitive impairments, including memory distortions (e.g., blackouts)
Ask about the following:
| 1. | Drug(s) of choice—ask specifically regarding alcohol, because some patients do not consider alcohol a drug | ||||
| 2. | Date and time of most recent use; date and time of maximum use/frequency | ||||
| 3. | Amount and route of administration of most recent use | ||||
| 4. | Habitual pattern | ||||
| 5. | Consequences of use (effects on family, job, schooling, friends, or health) | ||||
| 6. | Usual circumstances of use | ||||
| 7. | Age and circumstances of first exposure | ||||
| 8. | Source of supply (especially if substance is illicit or patient is underage) | ||||
| 9. | Amount of money spent per day/week/month | ||||
| 10. | Previous attempts to cut down or control use and results (longest period of abstinence and any withdrawal signs or symptoms) | ||||
| 11. | Previous chemical dependence treatment(s) and outcome (date/facility/length of stay/inpatient or outpatient/aftercare plans) | ||||
| 12. | Family history of substance use or abuse | ||||
| 13. | Present motivation for recovery | ||||
| 14. | Medical systems review, with special attention to items related to drug of choice and route of administration | ||||
Alcoholism
Screening Interview for Diagnosis of Alcoholism
Ask:
| 1. | “Do you drink?” If “no,” ask: “Why not?” (Looking for the abstaining alcoholic) If “yes,” ask: “How and when do you drink?” (Looking for alcoholic patterns—how much specifically quantified in ounces and/or size of the glass and how often) | ||||
| 2. | “Have you or close family members, friends, or coworkers ever been concerned about your drinking?” If spouse, family member, or friend is present, inquire directly: “Have you ever had concerns about or worried about your spouse’s/partner’s drinking?” If the patient presents unaccompanied, ask for permission to speak with someone directly regarding patient’s alcohol use. Collateral history can be very informative. | ||||
| 3. | “Has drinking ever caused problems in your life—with family, friends, the law, or at work?” Note: The same questions should also be asked to screen for illicit drug use or prescription drug abuse. | ||||
Alcoholic drinking patterns
Impulsive drinking
Gulping drinks
Drinking before attending social functions where alcohol will be served
Solitary or secret drinking; hidden bottle or supply
Morning drinking or morning tremor
Social isolation
Daily use or “binge” drinking
Drinking in inappropriate circumstances or to cope with stressors
Missed appointments/days at work due to drinking; attending medical appointment after drinking
Blood alcohol level
>100 mg/dL (0.1%) in a patient coming in for a general examination
>150 mg/dL (0.15%) in a patient without signs of intoxication
>300 mg/dL (0.3%) in a patient under any circumstances
Detection of drugs in blood and urine
The drug screen
The drug screen is a specific assay for a finite number of compounds. Drugs may be detected in urine, plasma, gastric juices, or other body fluids if the volume available is large enough. In general, urine testing is used to screen for the presence of compounds, with confirmation by assaying serum or plasma samples.
Screening for drugs of abuse
Drug Abuse Survey
The survey is useful as a quick screen for the presence of major categories of drugs of abuse. The Drug Abuse Survey is a urine test for alcohol, amphetamines, barbiturates, benzodiazepines, cocaine, opiates, phencyclidine, and tetrahydrocannabinol (THC) by class, with an immunoassay or thin-layer chromatography procedure. Results are presumptive because no confirmation is done. The false-positive rate for the screen is estimated to be 3% (i.e., of every 100 samples tested, three of them will have false-positive results for one of the drugs in the test group), whereas the false-negative rate for this screen is estimated to be low in the absence of adulterants. Thus, this test has a high true-negative rate. This test requires a random urine sample of at least 30 mL.
Drug Abuse Survey with confirmation
This is a urine test for the same drugs covered by the Drug Abuse Survey, but this assay uses gas chromatography–mass spectrometry (GC-MS) to confirm the results of the screening assay. This quantitative test is more accurate and sensitive and more expensive than the Drug Abuse Survey. The GC-MS may be used to test body fluids other than urine. This assay is recommended for employee screening programs or situations in which accuracy is paramount. Specimens should be collected under observation for greater reliability. Some states require that specimens collected for employee screening or forensic purposes be accompanied by documentation showing the chain of custody for each specimen. Substitute urine samples may produce false-negative results, and laboratory mix-ups can produce false-positive results. The GC-MS is considered the standard for testing for drug abuse and has a virtual 0% false-positive rate.
Interventions
Efficacious behavioral and psychotherapeutic interventions
Brief motivational interventions
Cognitive behavioral therapies
Contingency management
Multidimensional family therapy
Behavioral couples therapy
Efficacious pharmacotherapies
Opiates: methadone, LAAM, buprenorphine
Alcohol: naltrexone, disulfiram
Promising pharmacotherapies
Cocaine: vaccine
Marijuana: receptor antagonists
Alcohol: acamprosate
