How to Screen for Substance Abuse
Clinical tips and advice about:
- Conducting substance abuse screening and diagnosis with your patients
- Recognizing polysubstance abuse
- Physical and psychiatric comorbidities
Plus resources on each page with additional tips and tools!
| Written by Clinical Tools, Inc. [1] Reviewed by experts in buprenorphine treatment [2] Publication date February 9, 2009. |
Download Entire Guide [3] |
Substance Abuse Screening Guidelines
The NIH and SAMHSA recommend that physicians screen all patients over the age of 12 for potential substance abuse problems. Patients should be screened at every visit since substance use may change over time.
How To Do Substance Abuse Screening
- Conduct a simple initial screening by asking about tobacco, alcohol, and drug use during the patient interview.Use a routine and non-judgemental approach when asking these questions.
- Start with open-ended questions, "Tell me about your alcohol use?" instead of "Do you drink alcohol?" -- assuming that all patients consume some alcohol may yield more forthright answers. Prove responses by asking about frequency (how many days per week on average) and quantity (how many drinks on a typical day).
- Alternatively, incorporate a short substance abuse screening instrument, like the 4-item CAGE or CAGE-AID (adapted version that also includes drug abuse), into a health status questionnaire that all patients complete before their appointment. When substance abuse is indicated, follow-up with additional interview questions to learn more.
- Patients may be less honest about drug use, but many signs and symptoms of drug use can be identified through the physical exam, laboratory, or toxicological testing.
Risk Factors for Drug Dependence in Adolescents
You should routinely screen adolescents and young adults for substance use since they are at a high risk and since early intervention can significantly reduce health problems and costs associated with serious drug problems.
Look for these risk factors of substance abuse among adolescent patients
- substance abuse by a parent
- physical or sexual abuse
- smoking tobacco
- a dysfunctional family
- peers involved with drugs or alcohol (SAMHSA, 1997)
Physical and Psychological Symptoms of Opioid Dependence
Many patients who abuse opioids will not have any obvious physical symptoms. However, there are some signs to look for during the physical exam.
Look for these physical indicators of opioid dependence:
- In long-term intravenous drug users, look for needle marks or small scabs on their arms, legs, feet, groin (or really anywhere) or along vein lines.
- Look for irritation of the nose lining or perforated nasal septum in long-term users who take opioids intranasally.
- Pupillary constriction suggests that a patient may be currently intoxicated.
- Patient complaints of dry mouth, constipation, sexual dysfunction, or irregular menses are other indicators of opioid abuse.
Look for these psychosocial indicators of opioid dependence:
Many opioid dependent people go to great lengths to hide physical signs of their substance abuse. However, psychosocial indicators may also be present and more apparent. Consider the following psychosocial issues to be red flags among patients suspected of substance abuse:
- mood swings, depression, anger, irritability
- marital problems
- missing school or work
- poor performance at school or work
- financial problems, eg: large recent debt
- social isolation, loss of friendships
DSM Criteria for Substance Abuse and Dependence
You should familiarize yourself with DSM-IV criteria for substance abuse and dependence. Diagnostic criteria are not available for each substance, but specific DSM diagnostic codes can be used in the patient's chart to indicate the drug(s) of abuse.
Review printable fact sheets with the DSM-IV criteria:
- Substance Abuse [11]
- Substance Dependence [12]
Criteria for Substance Abuse
The following has been reprinted from the DSM-IV-TR with permission from the American Psychiatric Association:
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:
- Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
- Recurrent substance use in situations in which it is physically hazardous
- Recurrent substance-related legal problems
- Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance
- The symptoms have never met the criteria for Substance Dependence for this class of substance.
Criteria for Substance Dependence
The following has been reprinted from the DSM-IV-TR with permission from the American Psychiatric Association:
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:
- Tolerance, as defined by either of the following:
- a need for markedly increased amounts of the substance to achieve intoxication or desired effect
- markedly diminished effect with continued use of the same amount of the substance
- Withdrawal, as manifested by either of the following:
- the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
- the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
- The substance is often taken in larger amounts or over a longer period than was intended
- There is a persistent desire or unsuccessful efforts to cut down or control substance use
- A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
- Important social, occupational, or recreational activities are given up or reduced because of substance use
- 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
Recognizing Opioid Withdrawal
In many patients, you will able to identify opioid withdrawal by observing the patient and through physical exam.
Look for the following signs and symptoms of withdrawal:
- drug craving
- anxiety
- drug-seeking behavior
- yawning
- sweating
- lacrimation
- rhinorrhea
- mydriasis
- gooseflesh
- muscle twitching
- anorexia
- insomnia
- increased pulse, respiratory rate, and blood pressure
- abdominal cramps
- vomiting
- diarrhea
- weakness
You may wish to use the Clinical Opioid Withdrawal Scale, or COWS (see link below), to assess a patient's level of withdrawal. Many clinicians use this assessment tool with patients during the first stages of buprenorphine induction.
Signs and Symptoms of Polysubstance Abuse
Patients with opioid use disorders commonly have problems with other substances as well; in fact, polysubstance abuse is considered the norm rather than the exception (Patrick, 2003).
Among opioid addicts, cocaine and alcohol are the most frequently abused substances (Strain, 2002).
The signs and symptoms of polysubstance abuse include some of the same indicators for drug use in general.
Patients may or may not be dependent upon the various substances they are abusing, so it is important for you to assess the entire range of a patient's substance use.
Try these 4 main approaches for assessing opioid dependent patients for other substance abuse:
- Screening instruments: MAST [17], DAST [18], CAGE-AID [19], AUDIT [20]
- Clinical assessments: ask patient directly, ask family members
- Structured interviews: DSM-IV SCID-I [21] - Structured Clinical Interview for DSM-IV Axis I Disorders
- Laboratory tests: urine samples, preferably tested on-siteor via a lab with a quick turn-around time so that you can address results with the patient as soon as possible
CAGE-AID
- Have you ever felt you ought to cut down on your drinking or drug use?
- Have people annoyed you by criticizing your drinking or drug use?
- Have you ever felt bad or guilty about your drinking or drug use?
- Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
Scoring: A patient who answers positively to 2 or more questions is considered to be at risk.
The CAGE-AID questionnaire is reprinted with permission from Dr. R.L. Brown.
Reference:
Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorder among inpatients ages 18 to 49: an opportunity for prevention. Preventive Medicine. 1998;27:101-110.
Medical Comorbidities with Opioid Dependence
Medical complications can result from the opioid itself, as well as from the way it is administered. The main medical complications among the opioid-dependent population are related to injecting heroin.
You should routinely test these high-risk individuals for blood-borne and infectious diseases including the following:
- HIV
- Hepatitis B and C
- Tuberculosis
- Syphilis
You should also consider running these tests:
- CBC to detect occult infection
- Genital examination for chlamydia, gonococcal disease, and human papilloma virus
- Skin examination for cellulitis (Kleber et al, 2006)
Psychiatric Comorbidities with Opioid Dependence
Over 40% of opioid dependent individuals have co-occuring psychiatric disorders. The most common are depression, anxiety disorders, and bipolar disorder.
Psychiatric comorbidities may complicate buprenorphine treatment in terms of treatment priorities, stabilization concerns, and medication interactions. To make a sound treatment decision, you need to distinguish between independent and substance-induced disorders using the criteria below:
- Independent Disorders (Primary): continue to occur even when an individual is not using drugs for a sustained period of time, or have an onset before the opioid use disorder.
- Substance-induced Disorders (Secondary): all or most of the symptoms are the direct result of substance use.
Try these techniques to determine if the psychiatric problem is related or unrelated to the substance abuse:
- Observe the patient during a period of abstinence from the substance use
- Take a thorough history and, if possible, talk to family members or friends treat both problems simultaneously. If one disorder is not treated adequately or at all, both can become more severe.
- When possible, use medications that treat both disorders (Brady, 2006)
Topics to Discuss with Prospective Buprenorphine Patients
When prospective patients call your office to inquire about buprenorphine, it is helpful to have a standardized intake form or checklist available from which to ask questions and gather basic information over the phone.
- The intake checklist should include questions about opioid use and treatment history and can be administered via phone by administrative or clinical staff with minimal training.
- You should also gather information about the patient's health insurance and what insurances your practice accepts, because cost of treatment is a significant concern to many patients
Assessing and Selecting Patients for Buprenorphine Treatment
Some patients are better suited than others for buprenorphine treatment. Additionally, some patients are more challenging than others, either due to complicated medical or psychiatric issues, or problematic behaviors.
When first starting your buprenorphine practice, you may want to treat "easier" patients until you feel 100% comfortable with the induction and stabilization processes. Use a checklist and/or treatment screening form to assess patients before initiating treatment.
Review these conditions that might make a patient a less optimal candidate for buprenorphine treatment:
- significant medical problems (especially for psychiatrists)
- significant psychiatric comorbidity (especially for non-psychiatrists)
- chronic suicidal or homicidal thoughts (especially for non-psychiatrists)
- polysubstance use, including alcohol dependence
- dependence on benzodiazepines or other CNS depressants
- significant pain not management with non-opioid treatment alone
- frequent relapses in prior treatment attempts
- administrative discharges from more structured treatment settings (i.e. methadone maintenance)
- pregnancy (methadone is the standard of care for opioid-dependent pregnant women)
- any other condition that you feel is outside your realm of expertise
Summary
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Screen every patient over 12 for substance abuse
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Consider using a short, validated questionnaire
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Consider the risk factors
- Look for physical and psychological signs and symptoms
- Be familiar with common medical and psychiatric comorbidities
- Be familiar with signs of withdrawal
- Develop an initial phone contact protocol
