Substance Use Assessment

Chapter 6: Substance Use Assessment

Alcohol Use and Abuse

  • Overview

    • Alcohol is identified as the most frequently used and abused psychoactive drug in the United States.

    • Significant alcohol history can have substantial impacts on patients' health status.

  • Dose-Related Effects

    • Effects of alcohol consumption are dose-related; higher consumption equates to increased risk.

    • Morbidity and mortality statistics highlight the adverse effects of excessive alcohol use.

  • Medications and Alcohol Interaction

    • Many medications are classified as having interactions with alcohol.

    • Alcohol dependence correlates with higher risks of emergency department visits, intensive care unit admissions, and sepsis.

    • Binge drinking is linked to increased health risks.

Defining Illicit Drug Use

  • Categories

    • Seven categories of illicit drug use are recognized:

    • Marijuana

    • Cocaine (including crack)

    • Heroin

    • Hallucinogens

    • Inhalants

    • Methamphetamines

    • Non-medical use of psychotherapeutics (such as prescription pain relievers, tranquilizers, and sedatives).

  • Prevalence

    • Highest prevalence of illicit drug use is reported among individuals aged 12 years and older.

    • Illicit drug usage poses serious consequences for health, personal relationships, and future employment opportunities, education, and careers.

    • Risks arise from addiction and potential death due to substance use, with marijuana remaining illegal at the federal level.

Prescription Drug Abuse and Opioid-Related Deaths

  • Trends in Drug Overdoses

    • There has been an increased rate of deaths resulting from drug overdoses, surpassing the number of deaths from motor vehicle accidents.

  • Contributing Factors

    • Contributing factors to prescription drug abuse and the opioid crisis include:

    • Rise in prescriptions for pain medications.

    • Aggressive marketing strategies aimed at promoting medications.

    • Misrepresentation of the addictive nature of certain drugs.

    • Dual addictions stemming from the combination of alcohol and alcohol-interactive medications.

Diagnosing Substance Abuse

  • Diagnostic Standards

    • The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), provides a gold standard for diagnosing substance abuse.

    • Alcohol-related problems are often underdiagnosed in primary care and hospital settings.

    • Excessive alcohol consumption frequently goes unrecognized until serious health complications arise.

Genetics and Environment

  • Determinants of Vulnerability

    • The development of substance use disorders is a result of numerous interactional factors rather than a singular cause.

    • Family history (genetics)

    • Personal mental health history

    • Social determinants of health which influence an individual's susceptibility to substance use disorders.

Sexual and Gender Minority Considerations

  • Risk Factors

    • Members of the Sexual and Gender Minority (SGM) community are at a higher risk for substance use across their lifespans, often utilizing alcohol and illicit drugs as coping mechanisms for stigma and minority stress.

    • There are limited tailored interventions for this demographic.

    • Healthcare providers may harbor implicit biases against SGM individuals, necessitating further research and specialized treatment options for effective care.

Developmental Competence: Adolescents

  • Impact of Alcohol

    • Alcohol consumption during adolescence can hinder brain development and maturity.

    • The use of alcohol is associated with various high-risk behaviors including:

    • Sexual risk-taking

    • Academic issues

    • Trauma-related injuries

    • Propensity towards alcohol dependency in later life.

Developmental Competence: Pregnancy

  • Risks to Mother and Fetus

    • Alcohol poses a physical threat to both the mother and fetus.

    • Fetal Alcohol Spectrum Disorder (FASD) and its potential adverse outcomes are well documented, including physical deformities and cognitive/behavioral issues.

    • No safe amount of alcohol during pregnancy has been identified.

    • All women who are contemplating pregnancy or are currently pregnant should be screened for alcohol use, with complete abstinence recommended.

Developmental Competence: Aging Adult

  • Trends in Alcohol Use

    • An increasing number of older adults engage in alcohol consumption.

  • Risk Factors

    • Characteristics that heighten the risks associated with alcohol use in older adults include:

    • Decline in metabolic functions (liver, renal function, and water metabolism) leading to higher bioavailability of alcohol.

    • Reduced muscle mass increases body concentration of alcohol.

    • Polypharmacy concerns arise when medications interact with alcohol.

    • Increases vulnerability to cognitive decline.

    • Greater likelihood of falls, depression, and gastrointestinal issues linked to alcohol consumption.

Subjective Data

  • Collection Methods

    • Subjective data is collected by the examiner through structured questioning.

    • Challenges arise in gathering reliable data from patients who are currently intoxicated or undergoing withdrawal.

    • When patients are sober, they typically provide reliable data, especially in a private, confidential, and non-confrontational setting.

    • Essential questions include inquiries about the frequency of alcohol consumption:

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

    • Follow-up query for heavy drinking: "How many times in the past year have you had five or more drinks a day (men) or four or more drinks a day (women)?"

  • Screening Tools

    • Screening tools should be utilized to identify problem drinking, necessitating further assessment.

AUDIT Questionnaire

  • Structure and Purpose

    • The Alcohol Use Disorders Identification Test (AUDIT) is structured in a quantitative format that utilizes numerical responses across three domains:

    • Alcohol consumption

    • Drinking behavior or dependence

    • Adverse consequences

    • The maximum score on the AUDIT is 40, suitable for use in primary care, particularly among adolescents and older adults.

    • The AUDIT tool is designed to be relatively free from gender and cultural bias.

  • Short Form

    • AUDIT-C, a shorter version, is utilized in acute and critical care settings, with a maximum score of 12.

    • The AUDIT tool aids in identifying less severe alcohol issues, as well as abuse and dependence disorders.

    • Particularly useful in emergency department (ED) and trauma contexts due to sensitivity to current alcohol issues over those experienced in the past.

Standard Clinical Diagnostic Criteria

  • Assessment Focus

    • Assess for a maladaptive pattern of alcohol use causing clinically significant impairment or distress.

    • Inquiry examples from the past 12 months include:

    • "Has your drinking resulted in risk for bodily harm, relationship issues, role failings, or legal encounters?"

    • "Have you struggled to adhere to drinking limits, or found yourself exceeding them?"

    • Signs of tolerance, withdrawal, continued drinking despite complications, extensive time spent drinking or recovering, and neglecting other activities.

    • Additionally, ask about illicit substance use:

    • "Do you sometimes take illicit drugs or street drugs, such as marijuana, cocaine, hallucinogens, or narcotics? If so, when was the last time you used, and how much did you consume?"

TWEAK Questions

  • Purpose

    • TWEAK is a screening tool specifically designed to identify at-risk drinking in women, particularly those who are pregnant.

  • Questions Include

    • Tolerance: "How many drinks can you hold?" or "How many drinks does it take to feel high?"

    • Worry: "Have friends or family expressed concern about your drinking?"

    • Eye-opener: "Do you sometimes drink in the morning?"

    • Amnesia: "Have others told you about things you can't remember saying or doing?"

    • Kut down: "Do you feel a need to cut down on drinking?"

SMAST-G Questionnaire

  • Target Population

    • The SMAST-G questionnaire is tailored for older adults reporting regular or social drinking.

  • Characteristics

    • The questionnaire consists of 10 questions with yes or no responses that address specific emotional and physical reactions to alcohol.

    • An indication of an alcohol problem occurs when two or more responses are “yes.”

Advise and Assist (Brief Intervention)

  • Intervention Strategy

    • Due to the debilitating and destructive nature of substance abuse on patients and families, concise statements of concern and assistance should be offered.

    • If assessments confirm at-risk drinking or illicit substance use, provide clear conclusions and recommendations.

Objective Data: Clinical

Laboratory Data (1 of 2)

  • Self-Report Comparison

    • Laboratory data are less sensitive and specific than self-report questionnaires but may corroborate subjective findings.

  • Biochemical Markers

    • Serum protein gamma glutamyl transferase (GGT) is a commonly used biochemical marker for alcohol consumption:

    • Occasional consumption does not elevate GGT, but chronic heavy drinking does.

    • Nonalcoholic liver disease may also raise GGT levels without alcohol consumption.

    • Carbohydrate-deficient transferrin (CDT): Levels of CDT can vary by gender, with higher levels found in healthy females; combining CDT with GGT may improve diagnostic accuracy.

    • Serum aspartate aminotransferase (AST): Found in high concentrations in both the heart and liver, serving as another indicator of alcohol use.

Laboratory Data (2 of 2)

  • Additional Indicators

    • Mean corpuscular volume (MCV): This measures red blood cell size; while not sensitive enough as a standalone marker, it can detect early drinking after extended abstinence.

    • Direct biomarker phosphatidylethanol (Peth): This provides a sensitive measure for assessing abstinence.

    • Breath alcohol analysis: Detects alcohol levels in exhaled air after deep inhalation until the ingested alcohol is fully metabolized, correlating with blood alcohol concentration (BAC) and forming the basis of legal drinking interpretations.

Clinical Institute Withdrawal Assessment Scale (CIWA)

  • Assessment Tool

    • The CIWA scale is the most sensitive tool for objectively measuring withdrawal symptoms through 10 criteria with individual scoring contributing to a composite score.

  • Components

    • Criteria include vital signs and oxygen saturation levels.

    • Specific subscales total 7 criteria with Orientation assessed separately (4 criteria).

  • Monitoring Protocols

    • Continuous assessment yields trend results to determine necessary monitoring levels.

    • Scores of 0-7 allow monitoring every four hours; if scores remain below 8 for a continuous duration of 72 hours, monitoring may be discontinued.

Clinical Signs of Substance-Abuse Disorders

  • Substance Definition

    • Refers to non-medical agents used for altering mood or behavior.

  • Defining Intoxication and Abuse

    • Intoxication: Maladaptive behavioral changes stemming from the substance's effects on the central nervous system (CNS).

    • Abuse: Recurrent use leading to impairments and decline in functioning, resulting in ongoing issues.

    • Dependence: Physiological reliance on substance use.

    • Tolerance: Condition of requiring increased substance amounts for the same effects.

    • Withdrawal: Physiological reactions occurring upon cessation of substance use.