Assessment of Patients with Substance Use Disorders American Osteopathic Academy of Addiction Medicine
For This Presentation: Course Objectives ◼ At the conclusion of this presentation you will have a general understanding of the, diagnosis and screening of substance use disorders. ◼ You will be introduced to DSM-5 criteria ◼ You will receive an overview of SBIRT. ◼ You will learn about alcohol and drug laboratory testing
Diagnostic and Statistical Manual of Mental Disorders: DSM-5
Overview of Changes in the DSM-5 ◼ Removal of Roman numeral to modern Arabic numeral ◼ Elimination of multiaxial diagnostic system ◼ Elimination of NOS designation ◼ Dimensional (as opposed to categorial) approach to diagnosis ◼ Cultural formulation
Changes Specific to Substance Use Disorders ◼ Combines the DSM-IV categories of substance abuse and substance dependence into a single disorder ◼ Now have 11 criteria for substance-related disorders ◼ Eliminated criteria of recurrent substance related legal issues found in DSM-IV ◼ Added criteria of “craving, or strong urge to use”
Changes Specific to Substance Use Disorders ◼ Substance use disorders divided into two groups ◼ Substance use disorders (SUD) ◼ Substance-induced disorders (SID) ◼ Each disorder measured on a continuum from mild to severe ◼ Addition of first behavioral disorder, “gambling disorder”
What is a Substance Use Disorder? According to DSM – 5: A substance use disorder is a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of eleven criteria occurring in the preceding 12-month period.
DSM-5 Recommends Assessment of the Eleven Criteria be Based on… changes in report of frequency and/or individuals own knowledgeable dose of substance report others use clinician’s biological testing observations
The Eleven Criteria for a Substance Use 11 Disorder as Defined by DSM-5 1. Substance is often taken in larger amounts or over a longer period of time than was intended 2. Persistent desire or unsuccessful efforts to cut down or control substance use 3. Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 4. Craving or strong desire to use the substance
The Eleven Criteria for a Substance Use Disorder as Defined by DSM-5 5. Recurrent use resulting in failure to fulfill major role obligations at work, school, home 6. Continued substance use despite having persistent or recurrent social or interpersonal problems 7. Important social, occupational, or recreational activities are given up or reduced because of substance use
The Eleven Criteria for a Substance Use Disorder as Defined by DSM-5 8. Recurrent substance use in situations in which it is physically hazardous 9. 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
The Eleven Criteria for a Substance Use Disorder as Defined by DSM-5 10. 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. A markedly diminished effect with continued use of the same amount of substance
The Eleven Criteria for a Substance Use Disorder as Defined by DSM-5 11. Withdrawal, as manifested by either of the following: a. Characteristic withdrawal syndrome for the substance b. Use of the substance or closely related substance is taken to relieve or avoid withdrawal symptoms
The Eleven Criteria Grouped by Domains social risky use impairment (8 – 9) (5 – 7) pharmacological impaired control criteria (1 – 4) 11 (10 – 11) identified criteria
Significant Changes in Diagnostic Criteria ◼ Pharmacological criteria 10 and 11 which include withdrawal occurring during appropriate medical treatment with prescribed medications are specifically NOT counted when diagnosing a substance use disorder ◼ “…the appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of addiction even when these were the only symptoms present.”
Significant Changes in Diagnostic Criteria ◼ “however, prescription medications can be used inappropriately, and substance use disorder can be correctly diagnosed when there are other symptoms of compulsive, drug- seeking behavior”
Severity Specifiers in the DSM-5 mild severe 2-3 6 > moderate 4-5
Course Specifiers in DSM-5 • Early Remission • No Symptoms >3 <12 • Sustained Remission • No Symptoms for 12 months except cravings • In a Controlled Environment
10 Classes of Substances Listed in Substance-Related Disorders ◼ Alcohol ◼ Caffeine ◼ Cannabis ◼ Hallucinogens ◼ Inhalants
10 Classes of Substances Listed in Substance-Related Disorders ◼ Opioids ◼ Sedative-hypnotic, or anxiolytics ◼ Stimulants ◼ Tobacco ◼ Other (or unknown)
Non Substance-Related Disorders ◼ Gambling disorder ◼ Only behaviorally based disorder listed in substance related and addictive disorder chapter ◼ Has nine specific criteria
SBIRT S creening, B rief I ntervention, and R eferral for T reatment An Overview
SBIRT ( S creening, B rief I ntervention, and R eferral for T reatment ) will teach you how to: ◼ Conduct a screening ◼ Deliver a brief intervention ◼ Employ a motivational approach (another lecture)
SBIRT: Review of Key Terms Screening: Very brief set of questions that identifies risk of substance use related problems. Brief Intervention: Brief counseling that raises awareness of risks and motivates client toward acknowledgement of problem. Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help. Referral: Procedures to help patients access specialized care.
Benefits of SBIRT for Practice ◼ Offers clinicians more systematic approach to addressing substance use through the use of evidence based techniques
Screening to Identify Patients At Risk for Substance Use Problems A suggested approach
Types of Screening Tools ◼ Self-report ◼ Interview ◼ Self-administered short questionnaires ◼ Biological markers ◼ Breathalyzer testing ◼ Blood alcohol levels ◼ Indirect Markers ◼ Serum drug testing
Evidence-Based Screening Tools Source: https://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/screening-assessment-drug-testing-resources/chart- evidence-based-screening-tools-adults
Review of the AUDIT ◼ 10-question alcohol use screening instrument ◼ Designed for primary health care workers
Domains of the AUDIT Hazardous Alcohol Use ◼ Question 1: Frequency of Drinking ◼ Question 2: Typical quantity ◼ Question 3: Frequency of heavy drinking
Domains of the AUDIT (cont.) Dependence Symptoms ◼ Question 4: Impaired control over drinking ◼ Question 5: Failure to meet expectations because of drinking ◼ Question 6: Morning drinking
Domains of the AUDIT (cont.) Harmful Consequences of Alcohol Use ◼ Question 7: Guilt after drinking ◼ Question 8: Blackouts ◼ Question 9: Alcohol-related injuries ◼ Question 10: Others’ concerns about drinking
Alcohol Use Disorders Identification Test (AUDIT)
Scoring the AUDIT and Suggested Clinical Actions Score Level Action 0-7 Low Encouragement 8-15 Low/Moderate Brief Intervention 16-19 Moderate Brief Intervention or Referral for Treatment 20+ High Brief Cognitive Therapy or Referral for Treatment
Opioid Risk Tool
Drug Abuse Screening Test ( DAST - 10 )
Screening For Alcohol And Drug Use Disorders A suggested clinical approach Flexibility
Before Beginning: What is a standard “drink”? See reference list
Before Beginning: What is at risk drinking* Older Adults At-Risk Alcohol Use Men Women (65 +) Per occasion >4 >3 >1 Per week >14 >7 >7 *National Institute on Alcohol and Alcoholism (NIAAA) See reference list
Suggested Alcohol Screening: Example First ASK two questions: 1. “How many times in the past year have you had more than 4 (MEN) or more than 3 (WOMEN) drinks in a day?” 2. “How many drinks do you have in a typical week” A positive screen = any number on Q1 and on Q2 Men >14, Women > 7 See reference list
SUGGESTED DRUG USE SCREENING EXAMPLE ASK One Question: ◼ "How many times in the past year have you used an illegal drug or used a prescription medication for non- medical reasons?” Positive screen = 1 or more See reference list
Next Step for a Positive Alcohol or Drug Screen AUDIT/DAST or both
Pulling It All Together ASK : 2 Alcohol Pre- ASK : 1 Drug Pre- Screen Screen Questions…and if Question…and if Positive Positive then then Administer the Administer the DAST AUDIT And now what…
Pulling It All Together High Risk Moderate Risk At Risk • AUDIT • AUDIT • AUDIT 20 > 16-19 8-15 • DAST • DAST • DAST 6-8 3-5 1-2
Brief Interventions for Patients at Risk for Substance Use Problems
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