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Substance Use Assessment
Chapter 6
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Chapter 6: Substance Use Assessment
Alcohol Use and Abuse

Alcohol



Most used and abused psychoactive drug
Given rates of alcohol use, it is not surprising that
many patients in hospital and primary care find
themselves with alcohol-related disorders
Morbidity and mortality data reflect adverse
consequences of excessive alcohol use
• Alcohol is involved in 40% of 41,000 annual deaths due
to traffic accidents
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-2
Chapter 6: Substance Use Assessment
Alcohol Use and Abuse (cont.)

Alcohol (cont.)

Emergency department visits attributable to
alcohol from 1992 to 2000 was about 68.6 million,
with an increasing trend of 18%
• Alcohol consumption of four standard drinks per day or
more associated with increased rates of death in men
from:



Cirrhosis and alcoholism
Cancers of mouth, esophagus, pharynx, and liver
combined
Injuries and other external causes
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-3
Chapter 6: Substance Use Assessment
Alcohol Use and Abuse (cont.)

Alcohol (cont.)

In women, alcohol consumption increases risk of
breast cancer in a dose-response relation, starting
at an alcohol intake of about two drinks per day
 Link between chronic alcohol use and liver
disease is well known
 Chronic heavy use increases risk of alcoholic
cardiomyopathy, with an increase in left ventricular
mass, dilation of ventricles, and wall thinning
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-4
Chapter 6: Substance Use Assessment
Alcohol Use and Abuse (cont.)

Alcohol (cont.)

Hypertension is a common detrimental effect
 Because of alcohol related morbidity, many
patients encountered in primary care settings and
in hospital will have significant drinking history
 Alcohol dependence increases risk of sepsis,
septic shock, and hospital mortality among
intensive care unit (ICU) patients
 Excessive alcohol use increases risk for ICU
admissions due to trauma, hypothermia, and
pancreatitis
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-5
Chapter 6: Substance Use Assessment
Defining Illicit Drug Use

About 8% of Americans aged 12 or older
reported current illicit drug use in 2008

Illicit drugs include marijuana/hashish, cocaine
(including crack), heroin, hallucinogens, inhalants,
or prescription-type drugs used nonmedically
• Marijuana was most commonly used illicit drug with 6.1%
of persons aged 12 or older reporting past month use
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-6
Chapter 6: Substance Use Assessment
Defining Illicit Drug Use (cont.)

Illicit drug use has serious consequences for
health, relationships, and for future jobs,
school and career


Abuse of prescription drugs is fastest growing
drug problem in U.S.
Three most frequently abused prescription opioid
pain relievers were products using:
• Oxycodone
• Hydrocodone
• Methadone
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-7
Chapter 6: Substance Use Assessment
Diagnosing Substance Abuse

Rate of Americans classified with substance
abuse or dependence




9.2 % of the population aged 12 or older
68% of those were dependent on or abused
alcohol but not illicit drugs, and 14% used both
alcohol and illicit drugs
Alcohol dependence or alcoholism is a chronic
progressive disease that is not curable but is
highly treatable
Accurate diagnosis needed for advice,
intervention, appropriate treatment, and follow-up
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-8
Chapter 6: Substance Use Assessment
Diagnosing Substance Abuse (cont.)

Gold standard of diagnosis is well defined in
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV)


Alcohol problems under-diagnosed both in primary
care settings and in hospitals
Excessive alcohol use often unrecognized until
patients develop serious complications
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-9
Chapter 6: Substance Use Assessment
Developmental Competence

Pregnant woman

Among pregnant women 15 to 44
• About 10.6% report current alcohol use
• 4.5% reporting binge drinking and
• 0.8% reporting heavy drinking
• No amount of alcohol has been determined safe for
pregnant women
• Potential adverse consequences of alcohol use to fetus
are well known
• All women who are contemplating pregnancy or who are
pregnant should be screened for alcohol use, and
abstinence should be recommended
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-10
Chapter 6: Substance Use Assessment
Developmental Competence (cont.)

Aging adult

Prevalence of current alcohol use decreases with
increasing age
• 67.4% among those 26 to 29
• 50.3% among those 60 to 64
• 39.7% among those 65 or older
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-11
Chapter 6: Substance Use Assessment
Developmental Competence (cont.)

Aging adult (cont.)

Older adults have numerous characteristics that
increase risk of alcohol use
• Liver metabolism and kidney functioning decreases,
increase availability of alcohol in blood for longer periods
• Less tissue mass means increased alcohol concentration
in blood
• Older adults on multiple medications that can interact
adversely with alcohol, including benzodiazepines,
antidepressants, antihypertensives, and aspirin
• Drinking alcohol increases risk of falls, depression, and
gastrointestinal problems
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-12
Chapter 6: Substance Use Assessment
Subjective Data

If patient is currently intoxicated or going
through substance withdrawal, collecting any
history data is difficult and unreliable

However, when sober, most people are willing and
able to give reliable data, provided that setting is
private, confidential, and nonconfrontational
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-13
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use

Ask about alcohol use
• Do you sometimes drink beer, wine, or other alcoholic
beverages?

If answer is “Yes,” then ask screening question
about heavy drinking days, such as, “How many
times in past year have you had five or more
drinks a day (for men) or four or more drinks a day
(for women)?”
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-14
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)



To complete a picture of person’s drinking pattern,
ask, “On average, how many days a week do you
have an alcoholic drink?” and “On a typical
drinking day, how many drinks do you have?”
Recommend person stay at moderate drinking
patterns
Recommend even lower limits or abstinence for
patients who take medications that interact with
alcohol, who have a health condition exacerbated
by alcohol, or who are pregnant (advise
abstinence here)
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-15
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)

Use brief screening instruments to help identify
problem drinking and those who need more
thorough assessment
 AUDIT questionnaire
• A quantitative form that has the advantage of letting the
examiner document a number for a response so it is not
open to individual interpretation
• The AUDIT will help detect less severe alcohol problems
(hazardous and harmful drinking) as well as alcohol
abuse and dependence disorders
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-16
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)

AUDIT questionnaire (cont.)
• Helpful with emergency department (ED) and trauma
patients because it is sensitive to current, as opposed to
past alcohol problems
• Useful in primary care with adolescents and older adults
• Relatively free of gender and cultural bias

Note that AUDIT covers three domains
• Alcohol consumption
• Drinking behavior or dependence
• Adverse consequences from alcohol

The AUDIT-C is shorter form helpful for acute and critical
care units
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-17
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)

The CAGE questionnaire (Cutdown, Annoyed,
Guilty, Eye opener)
• Works well in primary care settings because it takes less
than 1 minute to complete
• The CAGE tests for lifetime alcohol abuse and/or
dependence


Does not clarify past problem drinking from present
Less effective with women and minority groups
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-18
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)


Assess for alcohol use disorders using standard
clinical diagnostic criteria
Determine whether there is a maladaptive pattern
of alcohol use causing clinically significant
impairment or distress
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-19
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)

Ask, “In past 12 months, has your drinking
repeatedly caused or contributed to:
• Risk of bodily harm: drinking and driving, operating
machinery, swimming?
• Relationship trouble: family or friends?
• Role failure: interference with home, work, or school
obligations?
• Run-ins with law: arrests or other legal problems?”

Ask, “In the past 12 months, have you not been
able to stick to drinking limits, or repeatedly gone
over them?”
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-20
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)

Ask, “In past 12 months, has your drinking
repeatedly caused or contributed to:
• Shown tolerance: needed to drink more to get same
•
•
•
•
effect?
Shown signs of withdrawal: tremors, sweating, nausea,
or insomnia when trying to quit or cut down?
Kept drinking despite problems: recurrent physical or
psychological problems?
Spent a lot of time drinking or anticipating or recovering?
Spent less time on other matters or activities that had
been important or pleasurable?”
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-21
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Alcohol use (cont.)

Ask about use of illicit substances
• “Do you sometimes take illicit drugs or street drugs, such
as marijuana, cocaine, hallucinogens, narcotics?”
• If yes, ask, “When was last time you used drugs, and
how much did you take that time?”
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-22
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Screening women for alcohol problems

The TWEAK questions help identify at-risk
drinking in women, especially pregnant women
• Tolerance: how many drinks can you hold? Or How
•
•
•
•
many drinks does it take to make you feel high?
Worry: have close friends or relatives complained about
your drinking?
Eye-opener: do you sometimes take a drink in morning
when you first get up?
Amnesia: has a friend or family member told you about
things you said but could not remember?
Kut down: do you sometimes feel need to cut down?
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-23
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Screening aging adults

Use the SMAST-G questionnaire for older adults
who report social or regular drinking of any
amount of alcohol
 Older adults have specific emotional responses
and physical reactions to alcohol and the 10
questions with yes/no responses address these
factors
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-24
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Advise and assist, brief intervention


Consequences of substance abuse are so
debilitating and destructive to patients and their
families that a short statement of assistance and
concern is given here
If your assessment has determined the patient to
have at-risk drinking or illicit substance use, state
your conclusion and recommendation clearly
• “You are drinking more than is medically safe.”
• Relate to the person’s concerns and medical findings, if
present; “I strongly recommend that you cut down, or
quit, and I’m willing to help.”
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-25
Chapter 6: Substance Use Assessment
Subjective Data (cont.)

Advise and assist, brief intervention (cont.)

If you determine the person has an alcohol use
disorder, state your conclusion and
recommendation clearly
• “I believe that you have an alcohol use disorder.”
• “I strongly recommend that you quit drinking, and I’m
willing to help.”

Relate to the person’s concerns and medical findings, if
present
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-26
Chapter 6: Substance Use Assessment
Objective Data

Clinical laboratory findings give objective
evidence of problem drinking

These are less sensitive and specific than selfreport questionnaires
• Useful data to corroborate subjective data
• Serum protein, gamma glutamyl transferase (GGT) is
most commonly used biochemical marker of alcohol
drinking
• Occasional alcohol drinking will not raise this measure,
but chronic heavy drinking will

Be aware that nonalcoholic liver disease also can increase
GGT levels in the absence of alcohol
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-27
Chapter 6: Substance Use Assessment
Objective Data (cont.)

Clinical laboratory findings give objective
evidence of problem drinking (cont.)
• From complete blood count, the mean corpuscular
volume (MCV) is an index of red blood cell size

MCV is not sensitive enough to use as only biomarker
– Can detect earlier drinking after long period of abstinence
• Breath alcohol analysis detects any amount of alcohol in
end of exhaled air following a deep inhalation until all
ingested alcohol is metabolized
• This measure can be correlated with blood alcohol
concentration (BAC) and is basis for legal interpretation
of drinking
Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Slide 6-28