Addictions 1

Assessment of Substance Use

Transition to PCE 8/16/16

Todd Griswold, MD
Dave Marcovitz, MD
Helen Farrell, MD
 Summary
Substance Use Disorders (SUD) overview
Spectrum of substance use, prevalence, definitions
Stigma

Specific substances
Forms, administration, pharmacology
Intoxication
Withdrawal

Clinical assessment
History, PE, MSE, Labs and other data
 Cases
34 yr old woman admitted to medicine with
fever and pneumonia, injection drug user

58 yr old homeless man picked up by

ambulance intoxicated on the street

45 yr old man with chronic schizophrenia,

brought to ED by police after erratic behavior
and agitation in a restaurant
 General Goals of Assessment
Identify SUD for appropriate interventions

Identify hazardous substance use and those at

risk for SUD

Identify substance use that can complicate

medical, surgical, psychiatric treatment
 Spectrum of substance use
No use
Low risk use
Harmful use, hazardous use, risky use
Compulsive use in the face of serious
consequences: severe SUD, addiction
Prevalence of Illicit Drug Use 2015:
SAMHSA - US National Survey on Drug Use and Health
Prevalence of SUD in US
 Substance Use Disorder
DSM 5 Diagnostic Criteria
A problematic pattern of substance use
Clinically significant impairment or distress
At least 2/11 criteria within a 12 month period
Criteria groupings:
1. Impaired control
2. Social impairment
3. Risky use
4. Pharmacologic criteria
 Impaired control
Amount
substance used in larger amounts or over longer than
originally intended
Cut down
persistent desire to cut down or regulate substance use
Time
spend a great deal of time obtaining the substance,
using the substance, or recovering from its effects
Craving
an intense desire or urge for the drug
 Social Impairment
Role obligations failure
failure to fulfill major role obligations at work,
school, or home
Social consequences
continued substance use despite having
persistent or recurrent social or interpersonal
problems
 Risky (Hazardous) Use
Physical risk
recurrent substance use in situations in which it is
physically hazardous

Continued use despite medical/psychological

problem
continued substance use despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely to have been
caused or exacerbated by the substance
 Pharmacologic Criteria
Tolerance: requiring a markedly increased dose of
the substance to achieve the desired effect
Withdrawal

NOTE: tolerance and withdrawal occurring during

appropriate medical treatment with prescribed
medications are specifically not counted when
diagnosing a substance use disorder.
 Specifiers
Specify if:
In early remission: none of the substance-related disorder criteria have
been met for at least 3 months but for less than 12 months.
In sustained remission: none of the criteria present for 12 months or
longer.
for these remission specifiers, the criterion craving, or a strong desire or urge
to use the substance, may be met.

Specify if:
On maintenance therapy (for opioid use disorder and tobacco use
disorder only)
In a controlled environment

Specify current severity:

Mild: 23 symptoms.
Moderate: 45 symptoms.
Severe: 6 or more symptoms.
 Severe SUD = Addiction
Complex biopsychosocial process that
becomes a chronic medical illness

3 Cs: loss of Control, Craving, Consequences

Severe SUD when the use of the substance has

taken over much of a persons life
 Changing concepts of Addiction

Moral failing of will

A spiritual problem
A character defect
An inherent quality of the substance
A disease
 Stigma
Stigma of SUD
https://www.youtube.com/watch?v=4Hlqw_E_WoI&in
dex=2&list=PL54knlBH64ADtWG6YD2s3n1MDzp27aM
Rk
https://www.youtube.com/watch?v=BUu7Ar1CEHE&in
dex=11&list=PL54knlBH64ADtWG6YD2s3n1MDzp27aM
Rk

Stigma of MAT
https://www.youtube.com/watch?v=bDtPaa7MWDE&li
st=PL54knlBH64ADtWG6YD2s3n1MDzp27aMRk&index
=4
 Stigma

What have you heard other healthcare

providers say (positive or negative) about
treating people with substance use disorders?

What sort of personal experience/exposure

have you had to substance use yourself,
family, friends and how might that affect
your attitude toward people with SUD?
 Terminology
Current Preferred Outdated or not preferred
Substance use disorder Substance abuse, substance
dependence
Person with substance use disorder Substance abuser, drug addict

Prescription Drug Misuse or non- Aberrant use

medical use
Hazardous, risky, or unhealthy substance Substance abuse
use
Sober, abstinent Clean
Positive/negative urine drug screen Clean/dirty urine
 Impact of stigma/bias in health care

Patients avoid treatment

Leads to lower quality medical and psychiatric
care
Decreased screening
Withholding of proper treatment (eg pain relief)
Abrupt termination of medical care if patient
relapses
Limited treatment resources
 Role of healthcare providers to
decrease stigma
Surgeon General
DPH Commissioner Monica Bharel
StateWithoutStigMA
Patient and family education
Educating colleagues, trainees, supervisors
Medical students teaching up