substanceabuseassessmentpreview

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Substance Abuse Assessment, Diagnosis,and Initial Treatment Planning for

Behavioral Health Clinicians

David Mee-Lee, M.D.

for

David Mee-Lee, M.D., Training and Consulting


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Selected Statistics

In 2002, 22 million Americans suffered fromsubstance dependence or abuse.

Nearly 14 million Americans meet criteria foralcohol abuse or alcoholism diagnosis.

40% of Americans have direct family experiencewith substance abuse or dependence.

About 1 in 4 children in the US are exposed toalcohol abuse or dependence in the family.

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An Opportunity

Being able to see past the vacuum of

lack of knowledge or skills, and the stigmathat clouds recognition and treatment ofsubstance use problems, provides for theastute clinicians a tremendous

opportunityan opportunity tointervene and arrest the havoc caused

by generations of untreated addiction.

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Attitudes Influencing Assessment & Treatment

Experiences shaping attitudes:

Antisocial

Self-destructive

Non-compliant

Out of control

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Factors contributing to negative attitudes:

Past experience with difficult clients

Negative societal attitudes

Inadequate education and skill training

Over exposure to chronic, relapsing clients

Lack of exposure to successfully recoveringclients

Lack of accessible treatment resources.

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Negative attitudes towards substance misuse:

Anger

Avoidance

Discouragement

Fatalism

Frustration

Futility

Hopelessness

Judgmentalism

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Consequences of negative attitudes: At-risk persons not recognized and

screened Affected persons not diagnosed and treated

Denial of existence of substance use

problems Enabling behavior (prescriptions, social

supports, etc.)

Punitive management Patronizing, nagging behavior

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Key Concepts About Addiction

Alcoholism and chemical dependence arebiopsychosocial-spiritual in nature.

In etiology, expression and treatment

As a consideration in differential diagnosis

Ask questions to make the diagnosis

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Denial and resistance are major signs andsymptoms characteristic of alcoholism and

chemical dependence.

Conscious lying

Organic amnesia

Unconscious survival mechanism

Implications for history-taking and treatment

planning

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Family disease concept

All members of the identified clients social systemsare affected and in need of active intervention.

Children, spouses, and significant others may

act to maintain and prolong addiction.

need to engage in a personal recovery.

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Treatment/Recovery is a process, not an event.

Motivation

Relapse

Levels of Care

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Screening and Diagnosis

Screening Principles

Reduce false positives and negatives

High sensitivity and high specificity

Simple and non-offensive to the client

Efficient use of time

Use a valid approach

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Interview Transition

Introduce next set of questions as routine Tobacco alcohol drugs

Family history of other conditions alcohol anddrugs

Diet history ask about alcohol use.

Stressors coping strategies

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Open-ended questions

Link questions to the presenting complaint

E.g. Have you found that with the depressionyouve been drinking more to try to cope?

Have you ever experimented with drugs?

Have you found yourself using more alcohol thanyou wanted?

How often do you get into arguments over alcohol

or other drugs at home or work?Use a brief validated screening tool.

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CAGE Questions*

Have you ever thought you shouldCut down on

your drinking (or drugging)?

Have others everAnnoyed you by criticizing your

drinking (or drugging)?

Have you ever felt bad orGuilty about your drinking(or drugging)?

Have you ever had a drink (or another drug) in the

morning (Eye-opener) to start your day or help youget over a hangover?

*Ewing, John A: Detecting AlcoholismThe CAGE Questionnaire

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TWEAK Questions* ToleranceHow many drinks does it take before you begin to feel the

first effects of the alcohol? Three drinks or more(2 points)

WorriedHave your friends or family complained about your drinkingin the past year? (2 points)

Eye OpenerDo you sometimes take a drink in the morning when youfirst get up? (1 point)

AmnesiaAre there times when you drink and afterwards you cantremember what you said or did? (1 point)

Kut (Cut)Do you sometimes feel the need to cut down on yourdrinking?(1 point)

*Bradley KA, et al: Alcohol Screening Questionnaires in Women

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TICSThe Two-Item Conjoint Screen*

In the past year, have you drunk alcohol or used drugsmore than you meant to?

In the past year, have you thought that you ought tocut down on your drinking or drug use?

*Brown RL, el al: A two-item screen for alcohol and other drug problems.

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UNCOPENorman G. Hoffman, Ph.D.

UIn the past year, have you ever drunk or Used drugs more

than you meant to?NHave you ever Neglected some of your usual responsibilities

because of using alcohol or drugs?

CHave you felt you wanted or need to Cut down on your

drinking or drug use in the last year?

OHas anyone Objected to your drinking or drug use?

PHave you ever found yourself Preoccupied with wanting touse alcohol or drugs?

EHave you ever used alcohol or drugs to relieve Emotionaldiscomfort?

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History of Trauma

Since your 18th birthday:

Have your had any fractures or dislocations to yourbones or joints?

Have you been injured in a road traffic accident?

Have you injured your head?

Have you been injured in an assault or fights?

Have you been injured after drinking?

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Quantity and Frequency

How many days a week do you typically have somealcohol?

How many drinks do you usually have on these days? Whats the most youve had to drink on any one day

over the past three months?

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Diagnostic Strategies

Assessing for Substance Abuse

Assessing for Substance Dependence

Assessing for Substance-induced Disorders

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Addiction Screening and

Brief Assessment Form*

I. Brief Substance Use History

II. Screening for Problem Use

III. DSM-IV Diagnostic Criteria

a. Substance Abuse

b. Substance Dependence

IV. Criteria for Brief Intervention or Addiction

Referral for AssessmentV. Action Plan

*See handout for the full form

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Focused, Targeted Treatment

Underlying Concepts

Move from program-driven treatment to assessment-based, clinically and outcomes driven treatment.

Biopsyhcosocial Perspective of Addiction

A common view allows a common language of assessmentand treatment

Individualized Treatment

A diagnosis is necessary, but not sufficient to determine

treatment.

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PATIENT PARTICIPANT ASSESSMENT

Data from allBIOPSYCHOSOCIAL

Dimensions

PLAN

BIOPSYCHOSOCIAL TreatmentIntensity of Service (IS)-Modalities & Levels of

Service

PROGRESS

Response to Treatment

BIOPSYCHOSOCIAL Severity (SI)And Level of Function

PRIORITIES

BIOPSYCHOSOCIAL Severity (SI)

And Level of Function (LOF)


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Underlying Concepts (cont)

Multidimensional Assessment

1. Acute intoxication and/or withdrawal potential

2. Biomedical conditions and complications3. Emotional/behavioral/cognitive conditions and complications

4. Readiness to change

5. Relapse/continued use/continued problem potential

6. Recovery environment

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Biopsychosocial Treatment5 Ms

MotivateDimension 4 Raising the bottom Motivational enhancement

Manage

The family, significant others, work/school, legal

Medication Detox, anti-craving meds, Antabuse, opioid antagonists,

methadone, LAAM, buprenorphine, psychotropic, etc.

Meetings AA, NA, Al-Anon, Smart Recover, Dual Recovery Anonymous, etc.

Monitor

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Treatment Levels of Service to matchseverity of the problems

Outpatient services

Intensive Outpatient/Partial Hospitalization Residential/Inpatient Services

Medically-managed Intensive Inpatient Services

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Decision Tree to Match Assessment and Treatment/Placement

What are the multiaxial DSM IV Diagnosis?

Multidimensional Severity/ LOF Profile

Identify which ASAM PPC assessment dimensionsare currently most important to determine Tx priorities

Choose a specific focus and target for each priority dimension

What specific services are needed for each dimension?

What dose of services is needed for each dimension?

Where can these services be provided-in the least intensive, safest level?

What is the progress of the treatment plan and

Placement decision, outcomes measurement?

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