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Chapter 5. Assessment of the Patient

Shelly F. Greenfield, M.D., M.P.H.; Grace Hennessy, M.D.
DOI: 10.1176/appi.books.9781585623440.349209

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Excerpt

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.

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TABLE 5–1. DSM-IV-TR criteria for substance dependence
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TABLE 5–2. DSM-IV-TR criteria for substance abuse
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TABLE 5–3. Medical problems associated with substance use disorders
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TABLE 5–4. Screening measures
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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.

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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Sample questions:
1.
In the assessment of substance abuse patients, it is most helpful to evaluate the usual mechanisms of psychological defense. Which of the following is not a typical defense encountered in substance abusers?
2.
Opioid withdrawal can be a polysymptomatic and physically uncomfortable condition that may, upon assessment, benefit from inpatient medical detoxification. Which of the following physical signs is not characteristic of opioid withdrawal?
3.
In the clinical classification of substance dependence, DSM-IV-TR provides several course specifiers by which the clinician may represent the course of illness. Which of the following is not a valid DSM-IV-TR course specifier for substance dependence?
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