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Transcript
The Outpatient Assessment Quinn T. Chipley, M.A., M.D. CAPTASA January 30-31, 2015 DISCLAIMER This presenter has no funding from any institution, corporation, or agency regarding the content of this presentation. Although he loves his work at the University of Louisville as the Counseling Coordinator for the Health Sciences Center students, that institution should in no way be held responsible for the content of this presentation. Old Rules and New Rules: Diagnostic Targets “The Times, They Are a Changin.’” DSM-IV-TR Criteria for Alcohol Dependence (Pertinent till October 2015) Alcohol Dependence - Diagnostic Code 303.90 A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1) tolerance, as defined by either of the following: (a) a need for markedly increased amounts of alcohol to achieve Intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of alcohol (2) Withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria sets for withdrawal from alcohol.) (b) alcohol (or a closely related drug such as valium) is used to relieve or avoid withdrawal symptoms (3) alcohol is often used in larger amounts or over a longer period than was intended (4) there is a persistent desire or unsuccessful efforts to cut down or control alcohol use (5) a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects (6) important social, occupational, or recreational activities are given up or reduced because of alcohol use (7) alcohol 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 alcohol (e.g. continued drinking despite recognition that an ulcer was made worse by alcohol consumption) DSM-IV-TR Criteria for Alcohol Abuse (Pertinent till October 2015) Alcohol Abuse - Diagnostic Code 305.00 A. A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: (1) recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household) (2) recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use) (3) recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct) (4) continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol (e.g., arguments with spouse about consequences of Intoxication, physical fights) B. The symptoms have never met the criteria for Alcohol Dependence. DSM-IV-TR Criteria for Alcohol Dependence (Pertinent till October 2015)- CONT. Specifiers: • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present) • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present) Course specifiers • Early Full Remission • Early Partial Remission • Sustained Full Remission • Sustained Partial Remission • On Agonist Therapy • In a Controlled Environment Side-Bar Note……. What happened to blackouts? I cannot find them mentioned directly, and it is a stretch to include transient neurological impairment under psychological sequleae. BUT I ALWAYS ASK: “Have you had drinking episodes in which other people report that you continued speaking, ambulating or engaging in other apparently conscious behaviors but you retained no memory of those events? DSM V Criteria for Substance Use Disorders(Pertinent after October 2015) “Criteria and Terminology DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather, criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substanceinduced disorders, where relevant. The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list, with two exceptions. The DSM-IV recurrent legal problems criterion for substance abuse has been deleted from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance, has been added. In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV substance dependence. Cannabis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”). Of note, the criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5. Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed: 2–3 criteria indicate a mild disorder; 4–5 criteria, a moderate disorder; and 6 or more, a severe disorder. The DSM- IV specifier for a physiological subtype has been eliminated in DSM5, as has the DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained remission is defined as at least 12 months without criteria (except craving). Additional new DSM-5 specifiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.” Source: http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf Two Occasions for the Outpatient Interview The General Intake Interview for all persons who present for medical or counseling services “All Comers” The Substance-focused interview when the referral indicates “For Cause” Three Possible Locations The “general practice” setting e.g. – psychology, LCSW, counseling practice, psychiatry, Family medicine, Internal Medicine, Pediatric, EAP A specific out-patient Substance Assessment and Treatment practice A Professionals’ Health organization (e.g. – physicians, dentists, nurses, pharmacists, et al.) The only real difference between “All Comers” and “For Cause,” and among the three locations, is the reduction of False Negatives and the increase in True Positives as “index of suspicion increases. This means that the good outpatient clinical interview will always include questions about alcohol and other substances Increased Suspicion Usually means Increased Assessment Time In an “All Comers” clinical interview of 50 minutes, I get to spend about fine minutes initially on substance issues. In a “For Cause” clinical Interview of 50 minutes, I get to spend as much as 25 minutes on substance issues The agency to which I most frequently refer students for who I detect substance problems will usually expect 2 hours and 15 minutes of time The Professionals Health Program interviews can involve several hours or more and also include a request for an observed urine laboratory panel. The General Intake Interview for “All Comers” Always ask the client about Substance use directly regardless of “presenting problem” or “chief complaint.” Use “Presumptive Interview” techniques e.g. – rather than asking “Do you drink alcohol?” start with the question “When was the last time you had an alcohol beverage?” (If the client is a non drinker, he or she will tell you immediately) Be Presumptive about All Substances, not Just Alcohol Ask, “What other recreational drugs do you use?” I also probe a bit even if none are offered. “Have you ever tried any anything, such as weed for example?” The General Intake Interview for “All Comers” – Cont. Ask for quantifiable answers: Ask for Frequency. (I scramble the possibilities: “Once a week? Once a month? Three times a week? Every day?”) Ask for Quantities: “Assuming a drink is one ounce of 80 proof or I glass of wine or one 12 oz. beer, how many drinks do you have an occasion? Ask for Excesses: “How many time in the past year have you had more than: [a) for a man, 4 drinks b) for a woman, 3 drinks] in a four hour period?” and “How many times in the past year would you guess that you would have exceeded a .08 blood alcohol level if you had been tested? Ask for family history of substance “Who in your family tree – up, down, or sideways along the branches – has or had a problem with alcohol or other drugs?” Use of Assessment Instruments C- Cut Back A – Angry G= Guilty E= Eye Opener Never sell-short the C-A-G-E. It may have limits (false negatives in particular) among women (especially pregnant women) and college-age drinkers, but results of 2/4 are a good indicator for further assessment; 3/4 is always a call to distinguish abuse from dependence (while that opportunity still lasts), and 4/4 can very well indicate a need for medical detox. For college age populations, there is some utility in substituting “Auto” for “Angry” and asking if the client thinks he or she has ever driven while drunk (even if never arrested fro the event). Instruments – Cont. The AUDIT (Alcohol Use Disorders Indication Test) Ten items long, forced-choice. Each scored 0 – 4. Includes aspects of CAGE and aspects of the quantifying questions. If you work in an environment that allows clients time to fill out forms in advance of an interview, consider it. You still have to ask about other substances See http://www.agencymeddirectors.wa.gov/Files/aas.p df Saunders JB, Aasland OG, Babor TF et al.. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption--II. Addiction.1993. 88: 791– 803 Instruments- Cont. SASSI-3 (Substance Abuse Subtle Screening Inventory-3) Paper or on-scree; 93 items for adults and 100 items for adolescents. Most useful, perhaps, as a way to document defensiveness. A good interviewer probably already knows the defensiveness is therein the client, but if a practice requires some more objective documentation, this can help.) Instruments- Cont. The MAC (McAndrew Alcoholism Scale)of the MMPI-2. 49 items out of the total 562 items. It hits “covert” content because the items do not directly mention drinking. If you have the luxury of an MMPI-2, it is worth looking at the MAC. For more information see: http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/41_MAC.pdf Cups, Needles and Clippers If you have the power, use it for good and not evil! There is SIGNIFICANT gain if you work in a setting that can mandate an unannounced lab screen (urine, plasma, or hair/ nails). Even before the results come back in, the client will often come back in to your office with a statement like, “Oh, I just remembered…I think maybe I DID take a hit off of….” or “You know, now that I think about it, I maybe had 6 or 7 beers yesterday an not just 1 or 2.” Placement? Not My Problem… Actually it is, but I am shamelessly shifting responsibility to the 96-hour residential assessment guys. And it is a problem if I know immediately that a client in front of me, whether “All Comer” or a “For Cause” needs medical detox as a way to prevent a seizure event; or even as means for compassionate reduction of suffering. I have to act to get those persons help immediately, and to inform them well of possible dangers if they refuse to take the bestpractices suggestions. That said, the legal-ethical assault on best-substance dependence practices has complicated the picture. Society is conspiring to make us watch folks fail lesser treatments before they get what works. (For me, this is a second-half of a first-step problem…)