About Course
Chapter 5. Assessment of the Patient
ASSESSMENT OF THE PATIENT: INTRODUCTION
Clinicians encounter patients with substance use disorders in all clinical settings. In 1995, health
care spending in the United States associated with alcohol, tobacco, and drug abuse was estimated
to be more than $114 billion (Horgan et al. 2001). It has been estimated that there were nearly 2
million drug-related emergency room admissions in 2004, and that out of those, approximately 1.3
million were associated with drug use or misuse (SAMHSA 2006). As much as 40% of medical
inpatient admissions are related to the complications of alcohol dependence (Horgan 1993), and on
any given day more than 900,000 individuals receive alcohol or drug treatment in specialized
treatment programs, with most of these receiving treatment as outpatients (Horgan et al. 2001).
There were nearly 1.7 million admissions to publicly funded substance abuse treatment programs
in 2003 (SAMHSA 2006). However, despite the prevalence of these disorders in both general and
treatment-seeking populations, substance use disorders are often undetected and undiagnosed in a
variety of clinical settings (Cummings and Cummings 2000; Deitz et al. 1994) and fewer than
one-third of physicians in the United States carefully screen for addiction (National Center on
Addiction and Substance Abuse 2000). A thorough and accurate substance use history should
therefore be a part of any medical or psychiatric interview.
A number of factors influence the accurate identification, assessment, and diagnosis of substance
use 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 patient’s
motivation and stage of readiness to change, the presence of another co-occurring medical or
psychiatric disorder, and the stage of use or abuse of the substance (e.g., current intoxication,
current withdrawal, early abstinence, sustained abstinence, or recent relapse).
Successful treatment of substance use disorders depends on a careful, accurate assessment and
diagnosis. The goals of assessment of patients with substance use disorders are 1) identifying the
presence of substance abuse or dependence, as well as identifying signs and symptoms of harmful
or hazardous substance use, so that prevention and early intervention might take place; 2) making
an accurate diagnosis and relating this to any other co-occurring medical or psychiatric disorder; 3)
formulating and helping to initiate appropriate interventions and treatment; and 4) enhancing the
patient’s motivation for change. In this chapter, we review principles of eliciting the history of
substance abuse, key elements of the patient history, formulation of an accurate diagnosis, the use
of biological tests and interviews with significant others, the use of screening instruments and
structured interviews, and the enhancement of motivation through the interview.
Work for this chapter was supported in part by grant K24DA019855 from the National Institute on Drug Abuse
(Greenfield). The authors gratefully acknowledge assistance preparing the manuscript from Rebecca Popuch,
B.A.
ELICITING THE SUBSTANCE ABUSE HISTORY
The interview and elicitation of the substance abuse history are essential to making an accurate
diagnosis. The setting of the interview, the clinician’s style of interviewing, and patient factors can
influence the accuracy of the history.
Setting
Accurate assessment is facilitated by interview settings that provide privacy and patient
confidentiality and permit adequate time to ask key questions, follow up on positive patientPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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responses, and give feedback to the patient. It is important to address patients’ concerns about
confidentiality (Senay 1997). Patients may worry about whether their history will be transmitted to
parents, spouses, employers, licensing boards, the courts, or other parties. The laws governing
patient confidentiality—especially with respect to substance abuse by minors—may vary according
to state or federal jurisdiction or with respect to the class of drug involved (e.g., narcotic treatment
supported by federal funds has strict safeguards for confidentiality). It is important for the clinician
to be aware of these particular laws and to communicate them to the patient (Senay 1997). In
particular, the U.S. Department of Health and Human Services issued the Standards for Privacy of
Individually Identifiable Health Information as part of the provisions of the Health Insurance
Portability and Accountability Act. This privacy rule requires that programs notify patients that
federal law and regulations protect the confidentiality of alcohol and drug abuse patient records
and give them a written summary of the regulations’ requirements (SAMHSA 2004). A statement
that gives the patient accurate information regarding confidentiality can be critical in the patient’s
willingness to provide a valid self-report. Similarly, privacy in the interview setting can also allow
the patient to feel comfortable providing an accurate history. Research studies have shown that
patients give valid self-reports when honest self-reporting is encouraged (Weiss et al. 1998) and
when they perceive few negative consequences.
The time allotted should be sufficient to accomplish the essential tasks of the interview. For
example, it is helpful to give the patient several minutes to freely describe his or her problem. The
clinician can then move toward a more active style of gathering the history through specific
questions. After completion of the history taking, there must be sufficient time for the clinician to
provide the patient with a summary of what he or she has heard from the patient, to provide
feedback about possible diagnoses and treatment options or recommendations, and to address the
patient’s specific questions.
Interviewing Style
The clinician’s attitude and style of history taking can also facilitate a thorough and accurate
assessment. One key to the accurate assessment of individuals with substance use disorders is to
be mindful of the great heterogeneity of these patients. Patients with substance use disorders may
be of any ethnic background, socioeconomic circumstance, age, gender, marital or partner status,
and level of employment. The epidemiology of substance use disorders reveals that there is no
“typical” person with substance abuse or dependence (Robins and Regier 1991). The first possible
mistake to be made in an assessment is not asking the appropriate questions to elicit the substance
use history because the patient does not fit a particular profile that the clinician has in mind. A
substance use history should therefore be obtained from all patients presenting for treatment.
Patients with substance use 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. 2000b). They often exhibit
certain typical defenses, including denial, minimization, rationalization, projection, and
externalization (Schottenfeld and Pantalon 1999). It is important to recognize these defenses and
note that they can present obstacles to obtaining an accurate history. A number of interview
strategies and approaches can help to circumvent these obstacles. It is often useful to begin the
interview by asking an open-ended question such as “How can I help you?” or “What brought you
here to see me today?” Allowing the patient to begin this way can help the clinician understand
how the patient defines the problem, and this can set the direction for the rest of the interview. At
the start of the interview, the clinician can permit the patient to take several minutes to further
elaborate his or her understanding of the nature of the problem before moving into a more active
and detailed mode of history taking. This also allows the clinician to get to know the patient more
fully before obtaining a detailed substance abuse history. For example, it is helpful to ask the
patient about other areas of his or her life history that might be less threatening, including work,
family, or relationships. This helps develop rapport with the patient and can help the patient feel
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Patients with substance use disorders may vary in their insight into the nature of the problem, their
readiness to change, their feelings of shame, or their own explanations for what has caused their
problem. For this reason, as in most psychiatric interviewing, asking questions in a simple and
straightforward manner and maintaining a nonjudgmental stance is most helpful. This may be
demonstrated by the phrasing of specific questions. For example, the clinician can ask, “How has
cocaine caused you problems?” rather than “How has your use of cocaine been a problem?” Instead
of asking “Why did you drink alcohol then?” the clinician might ask “How were you feeling before
you drank?” or “Do you think there were any specific circumstances or triggers to drinking at that
time?” Another approach to diminishing shame can be to phrase questions in a manner such as
“Some people with alcohol problems experience blackouts (or other negative consequence or
behavior). I am wondering if you have ever had that experience.” This technique can be used to
convey to the patient a range of experiences that others with similar problems have had and can
show that the clinician is knowledgeable about these experiences and is able to hear what the
patient might have to say, thereby serving to reduce shame. Clinicians can avoid using labels;
instead, they can ask patients to describe their pattern of use without labeling it. For example, if
the patient says, “I just drink socially but I am not an alcoholic,” the clinician can explain, “It
would be most helpful for me to be able to understand the pattern of your drinking, so if we look at
this past week/month/etc., tell me about your drinking.”
As in all clinical interactions, asking questions in an honest, respectful, and matter-of-fact manner
is likely to be most effective (Center for Substance Abuse Treatment 2004). Attributes of clinicians
that have been shown to be effective in establishing a therapeutic alliance with patients presenting
with addiction problems include respect, nonpossessive warmth, friendliness, genuineness,
empathy, a supportive style, reflective listening, and a patient-centered approach (Center for
Substance Abuse Treatment 2004; Miller and Rollnick 2002). Finally, it is also important that the
clinician’s interviewing style reflect cultural sensitivity, knowledge, and empathy (Westermeyer et
- 2004a). In practically all settings, clinicians will provide care for patients with diverse
backgrounds, and such culturally competent assessment is necessary when interviewing patients to
assess their substance use history. Clinicians’ attitudes toward their own substance use or non-use,
as well as toward their own cultural identity, can affect their attitudes toward patients’ substance
use, as well as toward patients’ cultural and ethnic identity (Westermeyer et al. 2004a).
Patient Characteristics
The interview can also be influenced by a number of patient characteristics that can affect the
clinical presentation of a substance use disorder. Bearing in mind this matrix of patient
characteristics can help the clinician adjust the interview to most effectively facilitate an accurate
history. These patient characteristics include
Age, gender, partner or marital status, legal and employment status, as well as culture and ethnicity
Degree of insight into and explanation for the nature of his or her problem
Medical or psychiatric comorbidity
Stage in the course of the illness (e.g., recovery, recent relapse, first treatment)
Current phase of use (e.g., intoxicated, withdrawing, interepisode)
Stage of readiness for change and motivation
A number of patient characteristics can influence the approach to the interview. For example, an
interview with an adolescent who is dependent on marijuana is likely to require a different
interview style than an interview with an elderly widow who has developed a drinking problem in
the several years following 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 consequence of these difficulties and not as the primary problem (Greenfield and O’Leary 2002;
Greenfield et al. 2007). Cultural norms may differ regarding the quantity or frequency of use of a
substance and may affect the social acceptability and the patient’s description of his or her use
(Westermeyer 1997). A growing literature emphasizes an ethnoculturally competent substance
abuse assessment that takes into account the patient’s views of how his or her ethnicity or culturalPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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background may affect the substance abuse history or treatment (Straussner 2001). Lack of
knowledge about the ways of life of others’ cultures (e.g., social roles, life-cycle rituals, family and
social organization, literature, art) or ethnic bias (e.g., bias toward a distinctive subgroup that
exists within a culture) can lead to inappropriate diagnosis and treatment (Westermeyer et al.
2006). Clinically relevant areas of inquiry for cultural influences on substance use include
normative versus deviant substance use, ceremonial versus secular substance use, and assessment
of the patient’s social network (Westermeyer et al. 2006). A patient’s marital or partner status and
employment status may also influence his or her presentation; individuals may present themselves
for evaluation because of the urging or demand of significant others or because of work or legal
complications resulting from their substance use.
The clinical presentation may also vary depending on whether the patient presents for treatment
early in the course of the illness or at a more advanced phase. For example, a patient who has
intermittent binge alcohol use may present for treatment after a recent legal charge of driving
while intoxicated. The patient’s alcohol use may not yet qualify for a diagnosis of an alcohol use
disorder. However, this interview may allow for identification of an alcohol problem early in its
evolution and may provide an opportunity for early intervention. This interview will likely differ in
scope and focus, for example, from that with a patient who has a 15-year history of alcohol
dependence presenting for a second admission for detoxification.
The current phase of drug use will also influence the clinical presentation and interview. Patients
may present in different clinical settings in a state of intoxication, withdrawal, remission, slip,
relapse, or maintenance. The clinician is unlikely to elicit a valid history from a patient who is
acutely intoxicated (Babor et al. 1987). If possible, during intoxication the interview may be
confined to the ascertainment of acute medical conditions in need of intervention (e.g., respiratory
depression, pancreatitis, gastrointestinal bleeding). 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, ascertainment of the medical need for detoxification and the prevention of
withdrawal complications are the most important goals of the assessment. Because untreated
alcohol withdrawal or sedative-hypnotic (e.g., benzodiazepines and barbiturates) withdrawal can
result in seizures, delirium tremens, and death, the clinician must first assess the patient for signs
and symptoms of withdrawal. The presence of such signs and symptoms, such as tachycardia,
diaphoresis, increased hand tremors, anxiety, psychomotor agitation, nausea or vomiting, and
transient perceptual disturbances (American Psychiatric Association 2000), indicates a need for
inpatient detoxification. Signs and symptoms of opioid withdrawal include dysphoric mood, muscle
aches, nausea or vomiting, lacrimation or rhinorrhea, yawning, fever, insomnia, as well as pupillary
dilation, piloerection (gooseflesh) or diaphoresis (American Psychiatric Association 2000, 2006;
Center for Substance Abuse Treatment 2004). 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. With the passing of the Drug
Addiction Treatment Act of 2000, outpatient detoxification and treatment with buprenorphine or
buprenorphine-naloxone may also be an option, and this can be assessed in the interview as well
(Center for Substance Abuse Treatment 2004). The clinician can assess if the patient is interested
in buprenorphine treatment and the patient’s appropriateness for such treatment by inquiring
about the patient’s understanding of the risks and benefits, ability to adhere to the treatment plan
and follow safety procedures, and medical and psychiatric conditions, including pregnancy, among
other factors (Center for Substance Abuse Treatment 2004). Generally, withdrawal syndromes
associated with the use of marijuana and stimulants such as cocaine 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, sustained remission from a substance use disorder but may
report symptoms of another medical or psychiatric illness or a new onset of urges and cravings. ItPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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is important in this instance to find out the supports the patient has used to maintain abstinence
and recovery, to examine how any other illness, whether it is chronic or of new onset, may be
affecting the patient’s ongoing recovery, and to ascertain what types of treatments or interventions
may help support the patient’s ongoing recovery. Similarly, the interview with 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 an effort to identify strategies that will help circumscribe
the relapse and help the patient get back on the recovery track.
The patient’s current stage of motivation for change will also 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. To establish a pattern of use, the
clinician might say to the patient, “It would be helpful for me to understand the pattern of your
alcohol/cocaine/marijuana/etc. use. As you know, people’s use of alcohol/cocaine/marijuana/etc.
varies greatly, and it would help me to understand the usual pattern for you.” The clinician might
then proceed to use a calendar method of ascertaining days of use in the past week, month, 3
months, 6 months, and year (Sobell et al. 1992). For the 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 the more distant time periods, it is helpful to anchor the questions in
seasonal events or events important to the patient. So, for example, the clinician might ask
whether the patient’s use was the same during the previous winter holidays as it is currently.
Alternatively, the clinician might ask the patient to compare the past week’s or month’s use of a
substance to previous 6-month time intervals, such as “Would you say the current pattern of use
that you just described is the same pattern you have had for the last 6 months? What about the
previous 6 months? Was there ever a period when you were using more heavily? When was that?”
A similar style of interviewing can be used to obtain the lifetime substance abuse history, with the
clinician asking for patterns of use during successive developmental periods, such as, “Tell me
about your first use. Your use in high school? College? Your twenties? After you were married?”
until the clinician is satisfied that he or she has understood the course of use throughout the
lifespan.
After identifying these use patterns, the patient might be encouraged to identify any ways in which
he or she perceives that the alcohol/cocaine/marijuana/etc. has caused negative consequences for
him or her. This interview will likely differ from interviews with patients who have had a brief
recent relapse after a sustained period of recovery. Elicitation of such patients’ earlier history is
likely to be more straightforward and to require less probing. Such patients are likely to provide an
overview of their previous substance problem and of what helped them in their recovery. These
interviews may be more likely to focus on the nature of the recent relapse, the particular triggers
to substance use, any consequences of the relapse, and plans to help the patient return to
abstinence and recovery.
As in all psychiatric interviews, the empathic stance is helpful. An empathic capacity to feel the
patient’s experience but at the same time to maintain objectivity is critical (Frances and Franklin
1989). Patients often feel great relief when they are asked questions about their condition, because
these questions reveal that the clinician is knowledgeable about the condition, can understand
what the experience of the condition might be like, and may be able to offer the patient relief
through some form of treatment. It is therefore also important to reserve time at the end of the
interview to summarize for the patient what the clinician has heard about the patient’s history, the
way in which the clinician formulates this, 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 saying, “I would like to save some time to give you feedback about what
we have discussed and to let you know some of my thoughts. Before I do this, is there anything
else that is important that we have not had a chance to discuss or that you think I haven’t asked
you?” After the patient has had a chance to add any further information, the clinician can then
present what he or she has heard. It is often useful to first let the patient know of any particularPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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risk factors or vulnerabilities that he or she may have. For example, the clinician might say, “It
sounds to me as if you have had a number of risk factors. You have told me that both of your
parents had alcohol problems, and we know that this is likely to have made you more vulnerable to
the substance. Second, you have told me 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 problems with drugs and alcohol.” The clinician might then proceed to
summarize the history the patient has given and to 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.
To elicit key elements of the history that allow the clinician to formulate the diagnosis and to relate
these elements back to the patient in a straightforward manner, it is important for the clinician 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 USE DISORDERS
Psychiatric disorders attributable to substances of abuse can generally be divided into disorders
produced by the substance’s pharmacological effects—such as intoxication, withdrawal, and
substance-induced disorders—and disorders related to the pattern or negative consequences of
such use (Woody and Cacciola 1997). In DSM-IV and DSM-IV-TR (American Psychiatric Association
1994, 2000), both categories of these disorders are covered in the section entitled
Substance-Related Disorders, which consists of two subsections, Substance Use Disorders and
Substance-Induced Disorders. The substance use disorders include both substance dependence and
substance abuse.
Substance Use Disorders
According to DSM-IV-TR, a diagnosis of substance dependence is made when there has been a
maladaptive pattern of substance use leading to clinically significant impairment or distress, as
manifested by at least three of seven symptoms or behaviors that have occurred within the same
12-month period. The DSM-IV-TR criteria for substance dependence are listed in Table 5–1. In
DSM-IV-TR, it is specified that the substance dependence diagnosis can be further characterized as
being “with physiological dependence” if the substance dependence diagnosis is accompanied by
evidence of tolerance or withdrawal or as being “without physiological dependence” when there is
no evidence of either tolerance or withdrawal.
TABLE 5–1. DSM-IV-TR criteria for substance dependence
A maladaptive pattern of substance 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 the substance to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria
sets for Withdrawal from the specific substances)
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken 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 substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors
or driving long distances), use the substance (e.g., chain-smoking), or recover from its effectsPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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(6) important social, occupational, or recreational activities are given up or reduced because of substance use
(7) the 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 (e.g., current
cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that
an ulcer was made worse by alcohol consumption)
Specify if:
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 (see text for definitions):
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
A diagnosis of substance abuse is made when the individual has never before met criteria for
dependence and exhibits a maladaptive pattern of substance use leading to significant impairment
or distress as manifested by any one or more behaviors that have occurred within a 12-month
period. The DSM-IV-TR criteria for substance abuse are listed in Table 5–2. Importantly, the criteria
for substance abuse or dependence are the same, regardless of the actual substance of abuse. The
presence of the behaviors and symptoms listed in Table 5–2 within the 12 months before the
interview constitutes a current diagnosis, and their presence in any 12-month period earlier in the
individual’s life is consistent with a past diagnosis.
TABLE 5–2. DSM-IV-TR criteria for substance abuse
- A maladaptive pattern of substance 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 substance 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 substance use; substance-related absences,
suspensions, or expulsions from school; neglect of children or household)
(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or
operating a machine when impaired by substance use)
(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused
or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of
intoxication, physical fights)
- The symptoms have never met the criteria for Substance Dependence for this class of substance.
DSM-IV-TR also provides for a number of course specifiers. Early full remission is specified if for at
least 1 month but for less than 12 months no criteria for dependence or abuse have been met. Early
partial remission is specified if for at least 1 month but less than 12 months one or more criteria for
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or continuously. Sustained full remission is specified when none of the criteria have been present
for 12 months or longer. Sustained partial remission is used when the full criteria for dependence
have not been met for a period of 12 months or longer but one or more criteria for dependence or
abuse have been present. The specifier on agonist therapy is used if the individual is taking a
prescribed agonist, partial agonist, or agonist/antagonist medication and no criteria for
dependence or abuse have been met for that class of medication for at least 1 month. The specifier
in a controlled environment is similarly used when there is full remission for a month or more and
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.
Harmful or Hazardous Substance Use
In addition to individuals who meet criteria for substance abuse or dependence, a significant
number of individuals use substances in a way that is harmful or hazardous even though their use
does not meet criteria for abuse or dependence or for another substance-related disorder. With
respect to alcohol, the World Health Organization defines hazardous drinkers as those whose
pattern of drinking poses a high risk of future damage to physical or mental health (Babor et al.
2001; Bohn et al. 1995). It defines harmful drinking as a pattern of alcohol use that is already
resulting in problems (Babor et al. 2001; Bohn et al. 1995). In addition to application of these
definitions of harmful and hazardous alcohol use, in the 10th Revision of the International
Statistical Classification of Diseases and Related Health Problems (ICD-10), harmful substance use
is defined as “clear evidence that the substance use was responsible for (or substantially
contributed to) physical or psychological harm, including impaired judgment or dysfunctional
behavior” (World Health Organization 1992). This category of harmful use is the closest that
ICD-10 comes to the DSM-IV-TR diagnosis of substance abuse. However, the DSM-IV-TR diagnosis
of substance abuse focuses on social consequences of behavior, whereas the ICD-10 definition of
harmful use focuses on psychological or physical harm. Importantly, the ICD-10 category of
harmful use has greater utility cross-culturally, because the social acceptability of substance use
may vary greatly from country to country (Woody et al. 1997).
Although the DSM-IV-TR diagnoses of substance use disorders are in wide use in the United States,
the concepts of hazardous or harmful substance use defined by the World Health Organization are
especially useful to consider when the patient describes the overuse or misuse of substances and
the pattern of use does not meet criteria for a DSM-IV-TR definition of a substance use disorder,
but the patient’s use of substances nevertheless increases vulnerability to developing a substance
use disorder or is currently creating some difficulties. Such an ascertainment allows the clinician
the opportunity to provide education and recommendations that may constitute early intervention
for an individual when problem use already exists or that may constitute prevention in the case of
someone whose use places him or her at risk. Certainly, an assessment of a patient’s risk factors
for developing a substance use disorder (e.g., family history of substance use disorder, personal
history of problems with the substance, the presence of another psychiatric disorder) may lead the
clinician to advise reduction or cessation of a particular substance even if abuse or dependence is
not yet present. In the case of patients with new-onset psychiatric illness, such as bipolar disorder
or schizophrenia, the risk of developing a substance use disorder is great. Moreover, intervention
that leads to cessation of any substance use is a good example of prevention (Brems et al. 2002;
Greenfield and Shore 1995).
Substance-Induced Disorders
Disorders produced by the direct pharmacological effects of the substance are referred to as
substance-induced disorders. These include the intoxication and withdrawal syndromes, as well as
syndromes such as substance-induced dementia and amnestic, psychotic, mood, anxiety, sleep, and
sexual dysfunction disorders. Although all categories of substances produce an intoxication
syndrome, the symptoms, signs, and durations of the syndromes vary by substance category. On
the other hand, according to DSM-IV-TR, not all categories of substances produce a withdrawalPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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syndrome or all of the other substance-induced disorders. Knowledge of the syndromes
characteristic of each category of substances is important in eliciting an accurate history and
clinical status.
CONTENT OF THE INTERVIEW
History of the Substance Use Disorder
An understanding of the major categories of the different substances of abuse provides the
interviewer with knowledge about their characteristic intoxication and withdrawal syndromes. With
this knowledge, the interviewer is better able not only to assess the patient but also to make
appropriate treatment recommendations. It is important to ask patients about all categories of
substances and not just the patient’s primary substance of abuse.
The major categories of substances of abuse are
Central nervous system depressants such as alcohol and sedative-hypnotics, such as barbiturates and
benzodiazepines
Stimulants, such as amphetamines, cocaine, and phencyclidine (PCP)
Cannabis (marijuana and hashish)
Opiates, including heroin, morphine, codeine, oxycodone, methadone, buprenorphine, and fentanyl
Hallucinogens, such as lysergic acid diethylamide (LSD), mescaline, and psilocybin (mushrooms)
Nicotine in the form of cigarettes, chewing tobacco or dip, and snuff
Inhalants, such as paint thinner, gasoline, glue, and cleaning fluids
Designer drugs, including 3,4-methylenedioxymethamphetamine (MDMA; “ecstasy”), ketamine, and
-hydroxybutyrate (GHB)
A systematic and organized way of collecting information about the patient’s history of substance
use is to address the following areas:
Age at first substance use
Frequency of substance use
Amount of the substance taken during an episode of use
Route of administration for the substance
Consequences associated with substance use
Treatment history
Periods of abstinence
Relapses
The information obtained by asking about the age at first substance-use episode serves as the
framework for the history and guides the interviewer’s subsequent questions. In addition, the
patient’s age when he or she began using substances has diagnostic and prognostic implications.
Studies have shown that early onset (before age 15 years) of substance use is associated with the
subsequent development of substance abuse and dependence (Chen et al. 2005; Hingson et al.
2006; Robins and Przybeck 1985; Wills et al. 1996). The early onset of substance use disorders has
also been associated with childhood psychopathology that preceded the development of the
substance use disorder (Hahesy et al. 2002; Ostacher et al. 2006).
The age at first use of nicotine is also an important component of the history of the substance use
disorder. Studies have shown that nicotine use often precedes experimentation with illicit drugs
(Adler and Kandel 1981; Warren et al. 1997; Yamaguchi and Kandel 1984a, 1984b) and is more
prevalent in individuals with other substance use disorders (Breslau et al. 1991; Budney et al.
1993; DiFranza and Guerrera 1990). Although it is incorrect to assume that all nicotine users have
also used illicit drugs or have another substance use disorder, the age at first use of nicotine in a
patient who uses other substances helps the interviewer have a more complete picture of the
patient’s history of substance use.
Once the age at first substance use is established, inquiries about the frequency of substance use
as well as the amount of the substance used and the route of administration (oral, inhaled,Print: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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insufflated or snorted, intravenous, subcutaneous) help the interviewer understand the progression
or regression 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 using three bags of heroin per day by the intravenous route is reporting her progression of
heroin use in all three areas. In addition, the frequency of use, the amount of the substance used,
and the route of administration may be related to the development of medical disorders associated
with a particular substance and will be relevant when discussing the patient’s medical history.
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 abuse. The history of substance abuse treatment includes
questions about hospital admissions for detoxification, as well as admissions to other controlled
living situations to support ongoing abstinence. Such programs include residential programs,
halfway houses, sober houses, and therapeutic communities. Outpatient programs such as partial
hospital programs, as well as group, individual, and pharmacological therapies (e.g., disulfiram,
naltrexone, nicotine delivery systems) 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. Finally, the interviewer should ask
about involvement in self-help groups such as Alcoholics Anonymous, Narcotics Anonymous,
Cocaine Anonymous, Self-Management and Recovery Training, Rational Recovery, and 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 should try to understand the patient’s reasons for such reactions, both to
educate the patient about self-help groups and to formulate a treatment plan that will be most
beneficial to the patient.
Other components of the history of substance use are the patient’s periods of abstinence and the
circumstances surrounding relapses. The information about abstinent periods and relapses
indicates the progression or regression of substance use, the severity of the substance use
disorder, and the external factors—such as relationship difficulties, psychiatric symptoms, legal or
medical problems, and treatment termination—that may have influenced the return to substance
use.
Finally, the interviewer should review other substances of abuse with the patient to ensure that no
other substances are being used currently or have been used in the past. A patient may say he only
has a problem with cocaine; however, by asking about other substances of abuse, the interviewer
may find that the patient has used marijuana daily for the past 10 years but did not mention the
marijuana use because he does not consider it to be problematic. Although daily marijuana use may
not be significant to the patient, this pattern of use could represent marijuana abuse or dependence
that should be addressed with the patient.
Psychiatric History
Research studies have demonstrated an increased prevalence of substance use disorders among
patients diagnosed with psychiatric disorders. For example, patients diagnosed with bipolar
disorder are six times more likely than the general population to have a co-occurring substance use
disorder (Regier et al. 1990). Other psychiatric disorders (Biederman et al. 2006; Hesselbrock et al.
1985; Kessler et al. 1997; Krausz et al. 1998; Regier et al. 1990; Rodriguez-Llera et al. 2006;
Rounsaville et al. 1991) and personality disorders (Helzer and Pryzbeck 1988; Rodriguez-Llera et
- 2006; Rounsaville et al. 1991; Weiss et al. 1993) have also been associated with substance use
disorders. Conversely, patients diagnosed with substance use disorders are more likely to have a
co-occurring psychiatric disorder (Brady et al. 1991; Currie et al. 2005; Drake and Wallach 1989;
Miller et al. 1989; Mueser et al. 1992, 2000). Studies have shown that the co-occurrence of
substance use disorders and psychiatric disorders can worsen the prognosis for both disorders
(Greenfield et al. 1998; Hides et al. 2006; Sonne et al. 1994; Weiss et al. 1988). By diagnosing
coexisting substance use and psychiatric disorders, however, patients can be referred to integratedPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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treatment for both disorders. There is increasing evidence that integrated treatment improves and
enhances outcomes for both disorders (Bennett et al. 2001; Mueser et al. 1992; Najavits et al.
1998, 2005; Weiss et al. 2000c). It is therefore important to assess substance use disorders in
patients presenting for the treatment of their psychiatric disorder and equally important to assess
psychiatric disorders among patients presenting for treatment of their substance use disorder.
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. Substance-induced psychiatric disorders occur when the
symptoms of the disorder represent a change in affective or cognitive states that arises from the
direct physiological effects of a substance. These symptoms are generally seen when the patient is
intoxicated or is experiencing withdrawal symptoms. Examples of substance-induced psychiatric
disorders include a patient who has exhibited symptoms of mania only when intoxicated with
cocaine and a patient who has had panic attacks only during benzodiazepine withdrawal. In
contrast, a psychiatric disorder is independent of a substance use disorder when the patient reports
a history of psychiatric symptoms that predates substance use or that does not resolve after the
substance use has been stopped.
A useful way to determine whether psychiatric disorders predate or continue after abstinence from
substances is to inquire about the presence or absence of psychiatric symptoms before the patient
began using substances and during periods of abstinence. For example, a patient who was
diagnosed with major depression 10 years ago and reports having used alcohol daily for the past 6
years in an attempt to ameliorate his untreated depressive symptoms had developed psychiatric
symptoms before the initiation of substance use. Similarly, a patient who says that he or she
continues to have auditory hallucinations 6 months after his or her last use of marijuana
demonstrates psychiatric symptoms that persist during a period of abstinence. 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 psychiatric disorders (which exist because of a
substance use disorder) and co-occurring psychiatric and substance use disorders.
Medical History
Evaluating clinicians need to elicit a complete medical history—including current and past medical
problems, surgical procedures, and medication allergies—from patients presenting for assessment
of a substance use disorder. Regardless of their relationship to substance use, medical problems
require treatment, and the interviewer would be remiss if he or she did not make inquiries about
medical conditions and recommend treatment or make referrals for further evaluation for any
conditions mentioned. In addition, patients with substance use disorders have often neglected their
health and routine medical care. The clinician can ask when was the last time the patient had a
complete physical examination and follow-up for any medical problems past or current.
As the patient describes symptoms of a medical disorder, the interviewer will want to determine if
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. For example, a patient reports that her asthma, which was
diagnosed at age 12 years, worsened about 2 years after she began smoking cigarettes at age 18.
Other questions for this patient would include the continuation or resolution of symptoms after
periods of abstinence. This same patient may report that when she stopped smoking for 2 weeks
she had fewer asthma attacks. The role of pharmacological interventions in the treatment of
medical disorders is another way to determine the effect of substance use on a medical disorder.
For example, this patient may also report the failure of her previously effective steroid inhalers to
treat asthma attacks in the past year. In this case, the patient’s cigarette use exacerbated her
asthmatic symptoms to the point that steroid inhalers were of limited therapeutic value.
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 ofPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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substances is beyond the scope of this chapter; the major medical problems and disorders
associated with the more commonly abused substances are listed below (see also Table 5–3):
Alcohol: blackouts, hangovers, withdrawal tremors, withdrawal seizures and delirium tremens,
aspiration pneumonia, cardiomyopathy, cerebellar degeneration, gastritis, gastroesophageal reflux
disease, hepatitis, pancreatitis, Wernicke-Korsakoff syndrome.
Cocaine: transient ischemic attacks, cerebral vascular events, ischemia of the gastrointestinal tract,
chest pain, and myocardial infarctions. Ischemic necrosis of the nasal septum is associated with
insufflating or snorting powder cocaine, whereas smoking crack cocaine may lead to dyspnea,
pneumothorax, pneumomediastinum, and pulmonary infarction. Intravenous cocaine use may cause
cellulitis or endocarditis.
Marijuana: the evidence for medical disorders associated with marijuana use is sparse and
inconclusive. Long-term marijuana use may be associated with the earlier development of respiratory
carcinomas in subjects who also use tobacco or alcohol (Taylor 1988), as well as an increased risk of
prostate and cervical cancer (Sidney et al. 1997).
Opiates: intravenous opiate use may result in the same medical disorders as intravenous cocaine use.
Other medical problems resulting from opiate use include constipation and, in overdose, respiratory
depression, coma, and death.
Nicotine: chronic obstructive pulmonary disease, emphysema, cardiovascular disease, peripheral
vascular disease, and lung and oral carcinomas.
Sedative-hypnotics: in overdose, respiratory depression, coma, and death; withdrawal tremors and
seizures, as well as a major abstinence syndrome.
TABLE 5–3. Medical problems associated with substance use disorders
Alcohol
Cocaine
Blackouts
Transient ischemic attacks
Hangovers Cerebral vascular events
Withdrawal tremors Ischemia of GI tract
Withdrawal seizures Chest pain
Delirium tremens Myocardial infarction
Aspiration pneumonia Pneumothorax (intranasal)
Cardiomyopathy Pneumomediastinum (intranasal)
Cerebellar degeneration Pulmonary infarction (intranasal)
Gastritis
Dyspnea (intranasal)
Gastroesophageal reflux disease Cellulitis (intravenous)
Hepatitis
Endocarditis (intravenous)
Pancreatitis
Opioids
Wernicke-Korsakoff Syndrome Constipation
Nicotine
In overdose:
Chronic obstructive pulmonary disease
Respiratory depression
Emphysema
Coma
Cardiovascular disease
Death
Peripheral vascular disease
Alcohol and illicit drugs
Lung cancer Hepatitis B
Oral cancer Hepatitis C
Sedative hypnotics
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Withdrawal tremors Tuberculosis
Withdrawal seizures
In overdose:
Respiratory depression
Coma
Death
Patients who abuse substances are at risk of contracting infectious diseases. Intravenous
substance use (most commonly heroin and cocaine) with contaminated needles can result in
infection with the human immunodeficiency virus (HIV), hepatitis B, and hepatitis C. Individuals
under the influence of substances may engage in risky sexual behaviors, resulting in exposure to
HIV, hepatitis B, hepatitis C, and the organisms that cause gonorrhea, chlamydia, syphilis, herpes,
genital warts, and human papillomavirus infection. Additionally, elevated rates of substance use
have been reported among individuals with tuberculosis (Centers for Disease Control and
Prevention 2007). In 2005, among approximately 13,000 tuberculosis cases in which information
about substance use was available, 2.2% were injection drug users, 7.8% were noninjection drug
users, and 13.9% were excessive alcohol drinkers (Centers for Disease Control and Prevention
2007). Because identification and treatment of infectious diseases has important implications for
the individual and society, the medical history should include questions about risk factors for
infectious diseases, as well as prior testing and treatment.
In the evaluation of women with substance use disorders, it is important to ask about reproductive
health history. Relevant history among women of childbearing age includes a menstrual history and
ascertaining whether the patient is or may be pregnant. Women who know they are pregnant may
wish to obtain additional information on risk to the fetus of the patient’s most recent or ongoing
substance use. If a pregnancy is in question, the patient can be offered a pregnancy test as well. A
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). Recent research emphasizes sex differences in all phases of the addiction process including
patterns and levels of use, as well as the progression of the addiction process and relapse (Lynch
2006). Women can experience changes in craving and substance use during different phases of the
menstrual cycle (Allen et al. 1999; Evans et al. 2002; Franklin et al. 2004; Snively et al. 2000) as
well as differences in likelihood of success in stopping their use of substances such as nicotine by
phase of menstrual cycle (Franklin et al. 2004; Perkins 2001). For women experiencing
perimenopause or for those who are postmenopausal, changes in sleep or symptoms such as hot
flashes may be relevant factors in use of substances.
Lastly, understanding the relationship between the development and exacerbation of medical
disorders and 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 use disorders may reveal a genetic vulnerability to the patient’s
own development of these disorders. In one study of 1,030 female twin pairs, it was estimated that
the heritability of alcohol dependence liability ranged from 51% to 59%, with the balance being
attributable to environmental factors (Kendler et al. 1992, 1994). These results are similar to the
estimate reported in studies of male alcohol-dependent twins (McGue 1994; National Institute on
Alcohol Abuse and Alcoholism 1997). Family (Bierut et al. 1998; Kendler et al. 1997; Merikangas et
- 1998; Mirin et al. 1991; Prasant et al. 2006), twin (Kendler et al. 2006; Kendler and Prescott
1998), and adoption (Cadoret et al. 1980, 1995) studies provide compelling evidence for the
relationship between genetic determinants and the development of substance use disorders. ThePrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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environment created by families who have substance use disorders may also have an impact on the
development of substance use disorders in their children. For example, parental modeling of
drinking behavior, ethnic differences in drinking customs, parental as well as familial
psychopathology, socioeconomic status, family aggression and violence, and parental cognitive
impairment are risk factors that have been shown to affect the development of both alcohol
dependence and other mental health problems in the children of alcoholic parents (Ellis et al.
1997). Interviewers can educate patients about genetic vulnerability to substance use disorder and
risk factors in the family environment associated with the development of substance use disorder,
which can 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
Patient social and developmental histories provide information about factors that may have
influenced the development and perpetuation of substance use disorders. An important
psychosocial factor to explore is the patient’s relationships with others (i.e., family, friends, peers,
significant others, authority figures). During adolescence, peer relationships are a powerful
influence on both the initiation and continued use of substances (van den Bree and Pickworth
2005). The interviewer will also want to know if the patient had any positive influences during
adolescence such as emotionally supportive parents, membership in school organizations, or a
focus on academic achievement; such factors are associated with a lower risk for substance use
(Brounstein et al. 2007; Kumpfer et al. 2007; Lochman et al. 2007).
Some patients may report both initial and continued use of substances because of the effects of
abusive relationships. Several studies have shown an association between self-reported histories of
physical and sexual abuse and the development of substance use disorders (Brown and Anderson
1991; Greenfield et al. 2002; Nelson et al. 2006; Rice et al. 2001; Wilsnack et al. 1997; Windle et al.
1995). A history of abuse may also be associated with poorer drinking outcomes in
alcohol-dependent subjects after treatment (Greenfield et al. 2002; Haver 1987). A study of
individuals who received intensive substance abuse treatment found that those with a lifetime
history of physical and/or sexual abuse had a worse psychiatric status, more psychiatric
hospitalizations, and more outpatient treatment at 1-year follow-up than those without an abuse
history (Pirard et al. 2005). Conversely, the ability to have meaningful interpersonal relationships
can help the patient build a social support network that might support recovery and help the
patient remain abstinent (Havassy et al. 1991).
Patients with substance use disorders may report the effects of substance use on their educational
attainment and subsequent employment. Studies have shown that substance use may lead to
school absenteeism, poor school performance, and dropout (Bray et al. 2000; Lynskey and Hall
2000; Lynskey et al. 2003). In turn, lower educational attainment has been associated with the
development of alcohol abuse and dependence in adulthood (Crum et al. 1992, 1993, 2006) and
may have effects on abstinence in alcohol-dependent individuals (Curran and Booth 1999;
Greenfield et al. 2003). By affecting educational attainment, alcoholism has been associated with
lower income and occupational status (Crum et al. 1998; Mullahy and Sindelar 1989).
Finally, the interviewer should inquire about the patient’s marital or partner status, because
studies have shown that the presence or absence of a spouse or partner can be an important
influence on the development and perpetuation of a substance use disorder and may also affect
treatment outcomes. For example, women seeking treatment for substance use disorders are more
likely than men to be single (Griffin et al. 1989; Weiss et al. 1997), to be involved with an addicted
partner (Gossop et al. 1994; Griffin et al. 1989; Hser et al. 1987), or to cite interpersonal factors
such as substance use by spouse, partner, or friend as reasons for their own continued substance
use (Greenfield 1996; Kandel and Logan 1984). The presence of a supportive partner (Anglin et al.
1987; Eldred and Washington 1976) and the absence of an addicted partner (Nurco et al. 1982)
have been shown to be the most consistent factors associated with better treatment outcomes for
opiate-dependent women but not for opiate-dependent men.Print: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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The social history, therefore, helps both patient and interviewer comprehend which interpersonal
relationships, negative experiences, and positive achievements shaped the development and
progression of the patient’s substance use disorder. These same factors may also affect the
outcome of the patient’s treatment for substance use disorders.
PHYSICAL AND MENTAL STATUS EXAMINATIONS
Physical and mental status examinations of patients presenting for an assessment of a substance
use disorder are a critical part of the evaluation because (as discussed earlier) 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 the physical examination. Lack of appropriate space, equipment, and training can interfere
with the interviewer’s ability to perform the physical examination. 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 at the time of
evaluation. 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 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). According to DSM-IV-TR, patients who are intoxicated with
amphetamines or cocaine may exhibit psychomotor agitation or retardation, diaphoresis, evidence
of weight loss, and confusion. Alcohol and sedative-hypnotics can cause slurred speech,
incoordination, unsteady gait, memory impairment, stupor, or coma in an intoxicated patient.
Similarly, opioid intoxication is characterized by slurred speech, drowsiness, and memory
impairment. One distinguishing characteristic of opioid intoxication is the appearance of pupillary
constriction; severe overdose of opiates can result in pupillary dilation secondary to anoxia in the
central nervous system.
Cannabis intoxication can cause motor incoordination, euphoria or anxiety, sense of slowed time,
and impaired judgment. An often obvious sign of cannabis intoxication is conjunctival injection. A
patient who is intoxicated with hallucinogens may be anxious, depressed, or paranoid after use.
Hallucinations, illusions, perceptual distortions, incoordination, diaphoresis, and tremors can also
be present. Signs of PCP intoxication include psychomotor agitation, impaired judgment,
dysarthria, sensitivity to sounds, ataxia, seizures, or coma. Inhalant use may cause euphoria and
impaired judgment, as well as a number of observable physical signs, including incoordination,
slurred speech, lethargy, ataxia, psychomotor retardation, stupor, or coma.
Also described in DSM-IV-TR are withdrawal symptoms for the different substances of abuse.
Patients withdrawing from either amphetamines or cocaine may present with dysphoria,
psychomotor agitation or retardation, and signs of fatigue; they may complain of increased
appetite, vivid and unpleasant dreams, insomnia, or hypersomnia. The withdrawal symptoms of
alcohol and sedative-hypnotics may include diaphoresis, tremulousness, psychomotor agitation,
responsiveness to internal stimuli, and seizures. Patients in withdrawal from central nervous
system depressants may also report anxiety, insomnia, nausea, and vomiting. Lacrimation,
rhinorrhea, pupillary dilation, piloerection, and yawning are the observable signs of opioid
withdrawal; symptoms that may be reported by patients undergoing opioid withdrawal are
dysphoria, fever, nausea, vomiting, muscle aches, and diarrhea. Cannabis, hallucinogens, PCP, and
inhalants do not have defined withdrawal syndromes.
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, small circular lesions representing the point of
injection of a drug into both large and small veins, also known as tracks, may be found when
examining a patient who uses drugs intravenously. If infected, these injection sites may be
erythematous, purulent, and warm to the touch. Similarly, a patient with hepatic damage secondaryPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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to chronic alcohol use or with hepatitis infection as a result of intravenous drug use may present
with scleral icterus or 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; these two examples are 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 use 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, causing
abnormalities in blood pressure, body temperature, and level of consciousness, and disrupting 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.
Biological Markers
Biological markers can help detect the degree and regularity of the patient’s substance use
(Kolodziej et al. 2002). These biological markers are most frequently tested and analyzed by
sampling breath, urine, blood, hair, and saliva. The highly sensitive and specific breath alcohol
testing provides immediate results at low cost and minimal discomfort to the patient. The
drawbacks of breath analysis include its narrow window of assessment, which varies from minutes
to hours after drinking, depending on the amount of alcohol consumed and on individual differences
in alcohol metabolism.
Metabolites of many substances of abuse are excreted in the urine and may be detected by urine
toxicology screens. The major disadvantage of urine testing is the variations in detection time for
the metabolites of different substances. For example, because cocaine metabolites remain in the
urine for approximately 3 days, a urine screening test performed 5 days after the last cocaine use
would not detect recent use. Conversely, cannabis metabolites may remain in the urine for a
month, resulting in positive urine toxicology screens after several weeks of abstinence. In turn, the
detection duration may be affected by dose, frequency of use, cutoff concentration level that
results in a positive urine screen, and the patient’s rate of metabolism (Cone 1997). Although
quantitative urine screening may overcome some of the limitations of urine toxicology screens and
reduces the numbers of false positive and false negative urine screens, the cost of this test may be
prohibitive, and the technology involved in qualitative urine screening requires further evaluation.
In addition, adulterants and urine substitutes designed to defeat urine toxicology tests are widely
available and can be easily researched and purchased over the internet, thus increasing the
possibility of false negative results for patients who may use these techniques (Jaffee et al. 2007).
Recent heavy substance use can be detected by serum testing. Alcohol exerts a direct toxic effect
on hepatocytes, leading to increased levels of glycoprotein carbohydrate-deficient transferrin
(Javors and Johnson 2003), glutamyltranspeptidase (Conigrave et al. 2003), serum glutamic
oxaloacetic transaminase (also known as aspartate aminotransferase or AST) and serum glutamic
pyruvic transaminase (also known as alanine aminotransferase or ALT). The mean corpuscular
volume of red blood cells may also be increased with heavy alcohol use, demonstrating hepatic
damage as well as hematological problems, such as deficiencies in vitamin B12 and folate. These
blood markers can help clinicians monitor changes in the patient’s physical health and may be used
as a motivator to help the patient decrease or abstain from the use of alcohol. These markers,Print: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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however, are not specific for alcohol-related medical problems and may be present with other
disease states. In addition, blood markers may differ due to individual factors such as age, body
mass index, gender, smoking, caffeine consumption, and the use of certain medications (Aubin et
- 1998; Daeppen et al. 1998).
A new method for evaluating biological markers of substance use is hair testing (Klein et al. 2000).
Although it is not fully understood how drugs enter the hair, hair testing may provide a longer time
to detect substance use because of the greater stability of the drug in hair samples compared with
samples of bodily fluids. The disadvantages of hair testing include the possibility of false positive
results due to passive contact with a substance, the possible effect of individual hair characteristics
(such as hair length) on the test results, and racial bias in hair testing. In addition, hair testing is a
new technology that cannot provide information about the amount of the substance used or the
temporal relationship between the presence of the substance in the hair and the use of the
substance.
Saliva testing is primarily used to detect very recent substance use and is used to identify
substance use in accident victims, automobile operators, and employees before their involvement
in activities in which safety is paramount. The detection time for saliva testing is relatively brief,
and the technology requires further evaluation to demonstrate its validity (Kaufman and Lamster
2002). Sweat testing may detect past substance use and may act as a cumulative measure of
substance use and may extend drug detection times by one week or longer compared with urine
testing, but it may be less sensitive than urine testing (Huestis et al. 2000). This test is not
commonly used because of individual variations in sweat production, possible environmental
contamination, and difficulties in collecting and storing sweat samples.
Testing for biological markers can serve an important function in the detection of substance use.
The evaluating clinician should consider the substance used, the duration for substance detection,
the invasiveness of the technique, and the expense of the test to determine which test is most
appropriate for individual patients.
Screening Instruments and Standardized Interviews
Standardized instruments exist for screening, diagnostic assessment, and evaluation of severity
(see Table 5–4). A number of short self-report instruments have been developed as screens for the
presence of a drug or alcohol use disorder (Allen and Columbus 1995; Kolodziej et al. 2002;
Rounsaville and Poling 2000). Such tests do not provide a formal diagnosis but rather provide an
indication of the likely presence of substance abuse or dependence.
TABLE 5–4. Screening measures
Screening
measure
Target population Groups used with Number
of items
Problem
screened
Cut-off
score for
harmful use
Time to
administer,
minutes
CAGE Adults Patients in ERs and
hospitals
Patients seeing
primary care
physician
4 Alcohol
dependence
1
(range 0–4)
<1
Alcohol Use
Disorders
Identification
Test (AUDIT)
Adults Patients seeing
primary care
physician
Patients in ER
DWI offenders
Employers for
workplace screening
10 (3) Harmful or
hazardous
alcohol use
8
(range 0–40)
3–5Print: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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Screening
measure
Target population Groups used with Number
of items
Problem
screened
Cut-off
score for
harmful use
Time to
administer,
minutes
Michigan
Alcohol
Screening
Test (MAST)
Adults and
adolescents
Psychiatric and
medical patients
Individuals with an
AUD
24 Problem
drinking
6
(range 0–22)
5
Short
Michigan
Alcohol
Screening
Test
(S-MAST)
Adults
(self-administered)
Adult patients in
medical and
psychiatric settings
13 Alcohol
dependence
Probable: >2
Likely: >3
(range 0–13)
1–2
Drug Abuse
Screening
Test
(DAST)-10
(shortened
DAST)
Adults (also
adapted for
adolescents)
Patients in medical,
primary care
settings and
psychiatric settings
0–10 Drug abuse Low: 1–2
Moderate:
2–5
Substantial:
6–10
(range 0–10)
1–2
TWEAK Adults Pregnant women
Other adult men
and women
5 Harmful
drinking
Pregnant
women: 2
Nonpregnant
adults: 3–4
(range 0–10)
<2
T-ACE Adults Pregnant women 4 Harmful
drinking
2
(range 0–5)
<2
CRAFFT Adolescents Adolescents/young
adults
Patients in
pediatric, medical,
or psychiatric
settings
6 Alcohol or
drug abuse
>1
(range 0–6)
2
Fagerström
Test for
Nicotine
Dependence
Adults, adolescents Smokers
Patients with
psychiatric
disorders or other
SUDs
Patients in medical
or psychiatric
settings
6 Nicotine
dependence
High level of
dependence:
>6
(range 0–10)
2
Note. AUD = alcohol use disorder; DWI = driving while intoxicated; ER = emergency room; SUD = substance
use disorder.
The CAGE Questionnaire (named for its four questions) (Kitchens 1994; Mayfield et al. 1974) asks
“Have you ever: 1) felt you should Cut down on your drinking? 2) felt Annoyed by criticism of your
drinking? 3) felt bad or Guilty about your drinking? 4) taken a drink first thing in the morning
(Eye-opener) to steady your nerves or get rid of a hangover?” The CAGE is useful because of its
brevity and ease of scoring. One positively answered question has a 90% rate of detecting an
alcohol-related disorder.
The Alcohol Use Disorders Identification Test (AUDIT) (Allen et al. 1997; Babor et al. 1992;Print: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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Donovan et al. 2006) was designed to screen hazardous or harmful alcohol consumption as defined
by the World Health Organization in a range of clinical and nonclinical settings. This 10-item
questionnaire uses a 0–5 score for each question and takes less than 2 minutes to administer and 2
minutes to score (Connors and Volk 2004). A score of 8 or more has reasonably good sensitivity in
detecting an alcohol use disorder (Conigrave et al. 1995). A three-item version (AUDIT-C) is also
available (Gordon et al. 2001; Piccinelli et al. 1997).
The Michigan Alcohol Screening Test (MAST) is useful in assessing the extent of lifetime
alcohol-related consequences (Allen et al. 1995; Westermeyer et al. 2004b). Commonly used are a
25-item self-test version (Selzer 1971), a 13-item short MAST (SMAST; Shields and Caruso 2003,
2004; Shields et al. 2007), and other shortened forms have also been developed (Connors et al.
2004).
The Drug Abuse Screening Test (DAST) (McCabe et al. 2006; Skinner 1982; Staley and el-Guebaly
1990) is a 20-item self-test designed to detect abuse of or dependence on a wide range of
substances other than alcohol.
The TWEAK test (the name is derived from its five items) was originally designed to screen for
high-risk drinking during pregnancy (Bush et al. 2003; Dawson et al. 2001). The T-ACE (Sokol et al.
1989) is a four-item test designed to identify pregnant women at risk for drinking alcohol in
quantities that might be dangerous to the fetus (Chang 2001). Neither the TWEAK nor the T-ACE
has gender-based items, and the TWEAK has been validated in both male and female populations
(Chan et al. 1993).
The six-question CRAFFT is designed for an adolescent population and covers both alcohol and
drugs (Knight et al. 2002). Questions focus on whether the adolescent has driven in a car with
someone who was using substances, uses drugs and alcohol to relax, uses them alone, forgets
things while using, has gotten into trouble while using substances, or has family or friends who
have asked for him or her to cut back. The CRAFFT is advantageous in adolescent and young adult
populations because of its brevity, ease of administration, and inclusion of items relevant to this
population. It is scored 0–6: a score of 1 provides a high sensitivity and a score of 2 has reasonably
good sensitivity and specificity (Knight et al. 2003).
The Risk Behavior Survey (RBS) is a brief questionnaire that assesses frequency of various HIV
sexual and needle-use risk behaviors and has established construct validity (Deren 1996) and
demonstrated test-retest reliability (Needle et al. 1995; Weatherby et al. 1994).
Several structured interviews that are used in research settings (Kolodziej et al. 2002) may also be
helpful in some clinical settings. The Timeline Follow-Back (TLFB; Sobell et al. 1992) uses a
calendar method that asks patients to reconstruct the type, quantity, and frequency of substance
use during a specific time period. The Addiction Severity Index (ASI; McLellan et al. 1992) was
developed as a structured interview to assess problem severity in seven areas frequently affected
by substance use disorders. There are several other questionnaires that measure other aspects of
severity. These include the Drinker Inventory of Consequences (Miller et al. 1995), which assesses
the adverse consequences of alcohol dependence, and the eight-item Clinical Institute Withdrawal
Assessment for Alcohol, Revised (CIWA-Ar; Sullivan et al. 1989), which provides a clinical
quantification of the severity of alcohol withdrawal syndrome. The Fagerström Test for Nicotine
Dependence (Heatherton et al. 1991; Sledjeski et al. 2007) was designed to provide an ordinal
measure of nicotine dependence related to cigarette smoking. The Clinical Opiate Withdrawal Scale
(COWS) is an 11-item screening tool with a possible score range between 0 and 48; it provides
ratings for four levels of withdrawal severity of opiate withdrawal (Center for Substance Abuse
Treatment 2004; Wesson and Ling 2003).
Structured interviews are also reliable ways to assess diagnostic information. The Structured
Clinical Interview for DSM-IV (SCID; Spitzer et al. 1992) is a clinically-based interview that aids in
diagnosis of DSM-IV-TR substance-related disorders and other psychiatric disorders. The
Psychiatric Research Interview for Substance and Mental Disorders (PRISM) facilitates diagnosis ofPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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DSM-IV-TR psychiatric disorders and demonstrates good reliability for establishing psychiatric
diagnoses among patients with drug and alcohol use disorders (Hasin et al. 1996).
INVOLVEMENT OF SIGNIFICANT OTHERS
People who seek assessment for substance use disorders often do so at the prompting of significant
others such as family members, friends, coworkers, or treating clinicians who are concerned about
the person’s well-being. Several studies have shown that significant others, serving as collateral
informants, can both corroborate and provide additional information about the patient’s reported
substance use history (Carroll 1995; Maisto et al. 1979; Sobell et al. 1997). Speaking to the
patient’s significant others also allows for their early involvement in treatment planning. As noted
in the section “Social and Developmental History,” establishing social networks may support the
patient’s recovery and help him or her remain abstinent (Havassy et al. 1991).
Contact with collateral informants should occur only with written permission from the patient. If
the request for contact with significant others is denied, it is appropriate to explore the patient’s
reasons for refusal. In some cases, the patient cannot provide the name of a collateral informant
because he or she is socially isolated and has no significant supports in his or her life (Weiss et al.
2000a). The patient may be ambivalent about changing his or her addictive behaviors and therefore
does not want significant others involved in his or her treatment. Other reasons that a patient
might refuse to authorize communication with certain individuals could include involvement of a
significant other in substance use; involvement of a significant other in physical, emotional, or
sexual abuse of the patient; and ability of a significant other to cause social consequences such as
unemployment or loss of significant relationships.
The involvement of significant others as both collateral informants and social supports can have
either a positive or a negative effect on the patient’s initiation of and retention in substance abuse
treatment. Because significant others may be a powerful influence in the patient’s life, it is
recommended that the interviewer contact only those who will support, rather than hinder, the
recovery process.
STAGES OF CHANGE AND MOTIVATIONAL INTERVIEWING
Before discussing treatment options with a patient who has a substance use disorder, the
interviewer will want to assess the patient’s willingness to stop using substances of abuse.
Prochaska et al. (1992) described the five stages of change that patients proceed through before
giving up their addictive behavior. Patients are said to be in precontemplation, the first stage, if
they do not want to change their addictive behavior. These patients may resist change because
they do not believe they have a problem or fail to see the seriousness of their problem with
substances. The second stage, contemplation, occurs when patients are aware of and are thinking
about changing their addictive behavior but have not yet committed to change. Patients may
remain in this stage for an extended period of time as they weigh both the positive and negative
aspects of continued substance use. When patients are in the preparation stage, they have decided
to change their behavior and will do so in the near future. Patients may prepare by reducing the
amount of the substance they are using or seeking a substance abuse treatment facility where they
may receive help for their problem. The fourth stage, action, occurs when patients are modifying
their addictive behavior, such as cessation of substance use. Finally, patients are in the
maintenance stage when they sustain their changed behaviors and continuously work on relapse
prevention. An example of maintenance would be a patient who has achieved 6 months of sobriety
and continues to attend self-help groups to receive support for his abstinence and to educate
himself about relapse prevention. The standard questionnaire, the University of Rhode Island
Change Assessment (URICA), is a 32-item instrument that can be used to formally assess a
patient’s readiness to change (McConnaughy et al. 1983).
Understanding the patient’s stage of change is important for treatment recommendations. For
example, a patient seeks a voluntary evaluation of marijuana use and says she is ready to stop
using marijuana. Recognizing that the patient is in the preparation stage, the interviewer may refer
this patient to an appropriate outpatient treatment such as psychotherapy, group therapy, orPrint: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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self-help groups. Giving this patient a follow-up appointment in 1 month to reevaluate her
marijuana use without any other treatment recommendations would be inappropriate because she
wants and is ready to change her addictive behaviors. The patient may rethink her decision to
abstain from all marijuana use during that month and may choose to not seek treatment at all.
For ambivalent patients in the contemplative stage, the interviewer can use motivational
interviewing (Miller and Rollnick 2002). Motivational interviewing primarily describes a therapeutic
style in which a therapist adopts a nonjudgmental and supportive stance to explore a patient’s
ambivalence about changing addictive behaviors. This emphasis on therapeutic style (also referred
to as adherence to the “spirit” of motivational interviewing) has recently found strong empirical
support that lends increased credence to the importance of the therapist’s interpersonal approach
to the client, as opposed to specified motivational interviewing techniques (Miller et al. 2005). The
desired outcome of motivational interviewing is the resolution of the patient’s ambivalence and the
facilitation of an increased readiness to consider actual behavior change. This method of
interviewing avoids confrontational questions and employs a communicative style that educes the
patient’s rationale for and the benefits of change. By using motivational interviewing, the
interviewer circumvents a patient’s defensiveness about substance use and creates an environment
where the patient may speak more freely about the advantages and disadvantages of change.
Support for the efficacy of motivational interviewing is mounting and a variety of meta-analytic
integrations yield significant reductions in substance use among clients receiving motivational
interviewing or adapted motivational interviewing interventions (e.g., Burke et al. 2003).
CONCLUSION
In this chapter we have discussed the importance of assessing use and abuse of substances 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, mental status examination, biological
markers, reports of significant others, and screening instruments. We have also provided
suggestions for the style of interviewing that will enhance accurate assessment and motivation to
change. 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
Successful treatment of substance use disorders depends on a careful, accurate assessment and diagnosis.
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.
A substance use history should be obtained from all patients presenting for treatment.
Patient assessment can be influenced by a number of patient characteristics including the patient’s age,
gender, ethnicity, 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, withdrawing, interepisode); and stage of readiness for
change and motivation.
In addition to diagnosing a substance-related disorder (e.g., a substance use disorder or a
substance-induced disorder), it is important to assess individuals for harmful or hazardous use of substances.
A complete substance use assessment will include eliciting history use for all the major categories of
substances addressing age of first use, frequency and amount used, consequences of use, and substance
abuse treatment history, as well as complete psychiatric, medical, family, and social and developmental
histories.
Biological markers that might be helpful in assessment include sampling of breath, urine, blood, hair, and
saliva. The most commonly used biological markers are breath alcohol testing, urine toxicology screens, and
serum testing of liver transaminases and carbohydrate-deficient transferrin.Print: Chapter 5. Assessment of the Patient http://www.psychiatryonline.com/popup.aspx?aID=349215&print=yes…
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Assessment can be enhanced by routine use of standardized screening instruments such as the Alcohol Use
Disorders Identification Test (AUDIT), the Drug Abuse Screening Test (DAST), the TWEAK or T-ACE, the
Addiction Severity Index (ASI), and the Risk Behavior Survey (RBS).
Significant others can both corroborate and provide additional information about the patient’s reported
substance use history, and their early involvement can be helpful in treatment planning.
For ambivalent patients who are contemplating their readiness to change, the interviewer can use
motivational interviewing techniques that include a nonjudgmental and supportive stance to explore the
patient’s ambivalence about changing addictive behaviors.
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SUGGESTED READING
American Psychiatric Association: Practice Guideline for the Treatment of Patients with Substance Use
Disorders, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2006
Cummings NA, Cummings JL: The First Session with Substance Abusers: A Step-by-Step Guide. San Francisco,
CA, Jossey-Bass, 2000
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Miller WR, Rollnick S: Motivational Interviewing: Preparing People for Change, 2nd Edition. New York, Guilford
Press, 2002
National Institute on Alcohol Abuse and Alcoholism: The Clinician’s Guide, Revised, 2005 Edition. Bethesda,
MD, National Institutes of Health, 2005
Copyright © 2008 American Psychiatric Publishing, Inc. All Rights Reserved.
Course Content
Introduction to Patient Assessment
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Understanding Patient Assessment
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Components of a Comprehensive Patient Assessment
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Initial Patient Interaction: Building Rapport
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Introduction to Patient Assessment Quiz
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Ethical Considerations in Patient Assessment
Understanding Patient History and Physical Examination
Advanced Techniques in Vital Signs Measurement
Integrating Diagnostic Tools in Patient Assessment
Synthesizing Assessment Findings: A Comprehensive Approach
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