Clinical assessment of substance use disorders
- Karen L Dugosh, PhD
Karen L Dugosh, PhD
- Senior Scientist
- Treatment Research Institute
- John S Cacciola, PhD
John S Cacciola, PhD
- Senior Scientist
- Treatment Research Institute
- Adjunct Professor of Psychology in Psychiatry
- Perelman School of Medicine at University of Pennsylvania
- Section Editors
- Richard Saitz, MD, MPH, FACP, DFASAM
Richard Saitz, MD, MPH, FACP, DFASAM
- Section Editor — Substance Use Disorders
- Professor of Community Health Sciences and Medicine
- Boston University Schools of Public Health and Medicine, Boston Medical Center
- Andrew J Saxon, MD
Andrew J Saxon, MD
- Section Editor — Substance Use Disorders
- Professor and Director, Addiction Psychiatry Residency Program, Department of Psychiatry & Behavioral Sciences
- University of Washington
Substance use disorders (SUDs) are highly prevalent. According to a 2015 national survey in the United States, approximately 8 percent of individuals age 12 or over had a diagnosable SUD in the past year, including about 6 percent with an alcohol use disorder and 3 percent with an illicit drug use disorder . Illicit drug use and nonmedical use of medications alone or in combination with alcohol are associated with a substantial proportion of emergency department visits in the United States .
A thorough substance use assessment includes a detailed inventory of the type, amount, frequency, and consequences of the patient's substance use, their perception of their use and readiness to change, an assessment of co-occurring psychiatric disorders, a medical history, physical examination and laboratory tests, the presence of substance use disorder in the patient's family, and review of social factors that may contribute to substance use or facilitate treatment.
The clinical assessment of substance use disorders is reviewed here. Screening for substance use is reviewed separately. The clinical presentation and diagnosis of SUDs specific to individual classes of substances are also reviewed separately. (See "Screening for unhealthy use of alcohol and other drugs in primary care" and "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis" and "Methamphetamine use disorder: Epidemiology, clinical manifestations, course, assessment, and diagnosis" and "Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations, medical consequences, and diagnosis" and "Cannabis use and disorder: Epidemiology, comorbidity, health consequences, and medico-legal status".)
Patients receive a substance use disorder (SUD) assessment when the possibility of an SUD has been established, for example, through screening, history, or one or more clinical findings. The purpose of a comprehensive SUD assessment is to:
●Determine the type and severity of a patient’s substance use
- Center for Behavioral Health Statistics and Quality. 2015 National Survey on Drug Use and Health: Methodological summary and definitions. 2016. http://www.samhsa.gov/data/ (Accessed on March 06, 2017).
- Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits, HHS Publication No. (SMA) 13-4760, DAWN Series D-39, Substance Abuse and Mental Health Services Administration, Rockville 2013.
- Center for Behavioral Health Statistics and Quality. Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). 2015. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf (Accessed on May 31, 2016).
- Gossop M, Griffiths P, Powis B, Strang J. Severity of dependence and route of administration of heroin, cocaine and amphetamines. Br J Addict 1992; 87:1527.
- National Institute on Alcohol Abuse and Alcoholism: Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. http://www.niaaa.nih.gov/guide (Accessed on May 31, 2016).
- Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617.
- Skodol AE, Oldham JM, Gallaher PE. Axis II comorbidity of substance use disorders among patients referred for treatment of personality disorders. Am J Psychiatry 1999; 156:733.
- Nunes EV, Selzer J, Levounis P, Davies CA. Substance Dependence and Co-Occurring Psychiatric Disorders, Civic Research Institute, Kingston 2010.
- National Institute on Drug Abuse. Medical Consequences of Drug Abuse. https://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse (Accessed on May 31, 2016).
- Saitz R. Medical and surgical complications of addiction. In: Principles of Addiction Medicine, ASAM, New York 2014. p.1027.
- Stein MD. Medical consequences of substance abuse. Psychiatr Clin North Am 1999; 22:351.
- Mertens JR, Flisher AJ, Satre DD, Weisner CM. The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug Alcohol Depend 2008; 98:45.
- Substance Abuse and Mental Health Services Administration. Clinical Drug Testing in Primary Care, Technical Assistance Publication (TAP) 32, HHS Publication No. (SMA) 12-4668, Substance Abuse and Mental Health Services Administration, Rockville 2012.
- Kendler KS, Davis CG, Kessler RC. The familial aggregation of common psychiatric and substance use disorders in the National Comorbidity Survey: a family history study. Br J Psychiatry 1997; 170:541.
- Orford J, Velleman R. Offspring of parents with drinking problems: drinking and drug-taking as young adults. Br J Addict 1990; 85:779.
- Merikangas KR, Stolar M, Stevens DE, et al. Familial transmission of substance use disorders. Arch Gen Psychiatry 1998; 55:973.
- Agrawal A, Lynskey MT. The genetic epidemiology of cannabis use, abuse and dependence. Addiction 2006; 101:801.
- Kendler KS, Karkowski LM, Neale MC, Prescott CA. Illicit psychoactive substance use, heavy use, abuse, and dependence in a US population-based sample of male twins. Arch Gen Psychiatry 2000; 57:261.
- Tsuang MT, Bar JL, Harley RM, Lyons MJ. The Harvard Twin Study of Substance Abuse: what we have learned. Harv Rev Psychiatry 2001; 9:267.
- van den Bree MB, Johnson EO, Neale MC, Pickens RW. Genetic and environmental influences on drug use and abuse/dependence in male and female twins. Drug Alcohol Depend 1998; 52:231.
- Tsuang MT, Lyons MJ, Meyer JM, et al. Co-occurrence of abuse of different drugs in men: the role of drug-specific and shared vulnerabilities. Arch Gen Psychiatry 1998; 55:967.
- Dube SR, Felitti VJ, Dong M, et al. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics 2003; 111:564.
- Kumpfer KL, Bluth B. Parent/child transactional processes predictive of resilience or vulnerability to "substance abuse disorders". Subst Use Misuse 2004; 39:671.
- Substance Abuse and Mental Health Service Administration. Risk and protective factors. Published October 2015. http://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/risk-protective-factors (Accessed on May 31, 2016).
- American Psychiatric Association. Diagnostic and Statistical Manual, 5th ed, American Psychiatric Publishing, Arlington 2013.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- Woody GE, Cacciola J. Diagnosis and Classification of DSM-IV-TR and ICD-10. In: Lowinson and Ruiz’s Substance Abuse: A Comprehensive Textbook, 5th ed, Ruiz P, Strain EC. (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.117.
- Cottler LB, Robins LN, Helzer JE. The reliability of the CIDI-SAM: a comprehensive substance abuse interview. Br J Addict 1989; 84:801.
- Haro JM, Arbabzadeh-Bouchez S, Brugha TS, et al. Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health surveys. Int J Methods Psychiatr Res 2006; 15:167.
- Horton J, Compton W, Cottler LB. Reliability of substance use disorder diagnoses among African-Americans and Caucasians. Drug Alcohol Depend 2000; 57:203.
- Wittchen HU. Reliability and validity studies of the WHO--Composite International Diagnostic Interview (CIDI): a critical review. J Psychiatr Res 1994; 28:57.
- Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59 Suppl 20:22.
- Kranzler HR, Kadden RM, Babor TF, et al. Validity of the SCID in substance abuse patients. Addiction 1996; 91:859.
- Steiner JL, Tebes JK, Sledge WH, Walker ML. A comparison of the structured clinical interview for DSM-III-R and clinical diagnoses. J Nerv Ment Dis 1995; 183:365.
- Williams JB, Gibbon M, First MB, et al. The Structured Clinical Interview for DSM-III-R (SCID). II. Multisite test-retest reliability. Arch Gen Psychiatry 1992; 49:630.
- Cacciola JS, Alterman AI, Habing B, McLellan AT. Recent status scores for version 6 of the Addiction Severity Index (ASI-6). Addiction 2011; 106:1588.
- McLellan AT, Cacciola JC, Alterman AI, et al. The Addiction Severity Index at 25: origins, contributions and transitions. Am J Addict 2006; 15:113.
- Denis CM, Cacciola JS, Alterman AI. Addiction Severity Index (ASI) summary scores: comparison of the Recent Status Scores of the ASI-6 and the Composite Scores of the ASI-5. J Subst Abuse Treat 2013; 45:444.
- The ASAM criteria :treatment for addictive, substance-related, and co-occurring conditions, Mee-Lee D. (Ed), American Society of Addiction Medicine, Chevy Chase 2013.
- Butler SF, Budman SH, Goldman RJ, et al. Initial validation of a computer-administered Addiction Severity Index: the ASI-MV. Psychol Addict Behav 2001; 15:4.
- Rosen CS, Henson BR, Finney JW, Moos RH. Consistency of self-administered and interview-based Addiction Severity Index composite scores. Addiction 2000; 95:419.
- Dennis ML. Global Appraisal of Individual Needs (GAIN): A standardized biopsychosocial assessment tool, Chestnut Health Systems, Bloomington 2010.
- Meyers K, Hagan TA, McDermott P, et al. Factor structure of the Comprehensive Adolescent Severity Inventory (CASI): results of reliability, validity, and generalizability analyses. Am J Drug Alcohol Abuse 2006; 32:287.
- American Society of Addiction Medicine, ASAM. Terminology related to the spectrum of unhealthy substance use. Published July 2013. http://www.asam.org/docs/default-source/public-policy-statements/1-terminology-spectrum-sud-7-13.pdf?sfvrsn=2 (Accessed on May 31, 2016).
- The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd ed., Mee-Lee D, Shulman GD, Fishman MJ, et al. (Eds), The Change Company, Carson City, NV 2013.
- Camilleri AC, Cacciola JS, Jenson MR. Comparison of two ASI-based standardized patient placement approaches. J Addict Dis 2012; 31:118.
- Stallvik M, Gastfriend DR, Nordahl HM. Matching patients with substance use disorder to optimal level of care with the ASAM Criteria software. J Subst Use 2014; 20:389.
- Miller WR, Tonigan SJ. Assessing drinkers' motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychol Addict Behav 1996; 10:81.
- Alterman AI, Cacciola JS, Ivey MA, et al. Reliability and validity of the alcohol short index of problems and a newly constructed drug short index of problems. J Stud Alcohol Drugs 2009; 70:304.
- Institute of Medicine. Improving the quality of health care for mental and substance use conditions: quality chasm series, The National Academies Press, Washington DC 2006.
- Knaup C, Koesters M, Schoefer D, et al. Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis. Br J Psychiatry 2009; 195:15.
- Poston JM, Hanson WE. Meta-analysis of psychological assessment as a therapeutic intervention. Psychol Assess 2010; 22:203.
- Goodman JD, McKay JR, DePhillipis D. Progress monitoring in mental health and addiction: a means of improving care. Prof Psychol Res Pr 2013; 44:231.
- McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008; 337:a2038.
- Marlowe DB, Festinger DS, Dugosh KL, et al. Adaptive Programming Improves Outcomes in Drug Court: An Experimental Trial. Crim Justice Behav 2012; 39:514.
- Brooner RK, Kidorf M. Using behavioral reinforcement to improve methadone treatment participation. Sci Pract Perspect 2002; 1:38.
- McLellan AT, McKay JR, Forman R, et al. Reconsidering the evaluation of addiction treatment: from retrospective follow-up to concurrent recovery monitoring. Addiction 2005; 100:447.
- Cacciola JS, Alterman AI, Dephilippis D, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treat 2013; 44:256.
- Marsden J, Farrell M, Bradbury C, et al. Development of the Treatment Outcomes Profile. Addiction 2008; 103:1450.
- SUBSTANCE USE
- Type, frequency, and amount
- - History of prior SUD, treatment
- Route of administration
- MENTAL HEALTH
- Mental status examination
- GENERAL MEDICAL
- Physical examination and medical history
- Laboratory tests
- FAMILY HISTORY
- SOCIAL HISTORY
- DSM-5 diagnostic criteria
- - Severity
- - Diagnostic tools
- Multidimensional assessment
- Progress monitoring
- Withdrawal potential
- APPLICATION TO TREATMENT PLANNING
- SUMMARY AND RECOMMENDATIONS