Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Chapter 6
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Chapter 6: Substance Use Assessment
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Chapter 6: Substance Use Assessment
Alcohol
Most used and abused psychoactive drug

Many patients in hospital and primary care find
themselves with alcohol-related disorders

Morbidity and mortality data reflect adverse
consequences of excessive alcohol use
Alcohol is involved in 40% of 41,000 annual deaths due
to traffic accidents
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Chapter 6: Substance Use Assessment
Alcohol (cont.)
ED visits attributable to alcohol from 1992 to 2000
was about 68.6 million, with an increasing trend of
18%
Alcohol consumption of four standard drinks per day or
more associated with increased rates of death in men
from:
Cirrhosis and alcoholism
Cancers of mouth, esophagus, pharynx, and liver combined
Injuries and other external causes
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Chapter 6: Substance Use Assessment
Alcohol (cont.)
Women, alcohol consumption increases risk of
breast cancer in a dose-response relation, starting
at an alcohol intake of about two drinks per day
Link between chronic alcohol use and liver
disease is well known
Chronic heavy use increases risk of alcoholic
cardiomyopathy, with an increase in left ventricular
mass, dilation of ventricles, and wall thinning
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Chapter 6: Substance Use Assessment
Alcohol (cont.)
Hypertension is a common detrimental effect
Because of alcohol related morbidity, many patients
encountered in primary care settings and in hospital
will have significant drinking history
Alcohol dependence increases risk of sepsis, septic
shock, and hospital mortality among intensive care
unit (ICU) patients
Excessive alcohol use increases risk for ICU
admissions due to trauma, hypothermia, and
pancreatitis
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Chapter 6: Substance Use Assessment
About 8% of Americans aged 12 or older
reported current illicit drug use in 2008
Illicit drugs include marijuana/hashish, cocaine
(including crack), heroin, hallucinogens, inhalants,
or prescription-type drugs used nonmedically
Marijuana was most commonly used illicit drug with
6.1% of persons aged 12 or older reporting past month
use
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Chapter 6: Substance Use Assessment
Serious consequences for health,
relationships, and for future jobs, school
and career
Abuse of prescription drugs is fastest growing
drug problem in U.S.
Three most frequently abused prescription opioid
pain relievers were products using:
Oxycodone
Hydrocodone
Methadone
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Chapter 6: Substance Use Assessment
Rate of Americans classified with substance
abuse or dependence
9.2 % of the population aged 12 or older
68% of those were dependent on or abused alcohol
but not illicit drugs, and 14% used both alcohol and
illicit drugs
Alcohol dependence or alcoholism is a chronic
progressive disease not curable but highly treatable
Accurate diagnosis needed for advice, intervention,
appropriate treatment, and follow-up
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Chapter 6: Substance Use Assessment
Pregnant woman
Among pregnant women 15 to 44
About 10.6% report current alcohol use
4.5% reporting binge drinking and
0.8% reporting heavy drinking
No amount of alcohol has been determined safe for
pregnant women
Potential adverse consequences of alcohol use to fetus
are well known
All women who are contemplating pregnancy or who
are pregnant should be screened for alcohol use, and
abstinence should be recommended
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Chapter 6: Substance Use Assessment
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Chapter 6: Substance Use Assessment
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Chapter 6: Substance Use Assessment
Aging adult
Prevalence of current alcohol use decreases with
increasing age
67.4% among those 26 to 29
50.3% among those 60 to 64
39.7% among those 65 or older
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Chapter 6: Substance Use Assessment
Aging adult (cont.)
Older adults have numerous characteristics that
increase risk of alcohol use
Liver metabolism and kidney functioning decreases, increase
availability of alcohol in blood for longer periods
Less tissue mass means increased alcohol concentration in
blood
Older adults on multiple medications that can interact
adversely with alcohol, including benzodiazepines,
antidepressants, antihypertensives, and aspirin
Drinking alcohol increases risk of falls, depression, and
gastrointestinal problems
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Chapter 6: Substance Use Assessment
If patient is currently intoxicated or going
through substance withdrawal, collecting
any history data is difficult and unreliable
However, when sober, most people are willing and
able to give reliable data, provided that setting is
private, confidential, and nonconfrontational
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Chapter 6: Substance Use Assessment
Alcohol use
Ask about alcohol use
Do you sometimes drink beer, wine, or other alcoholic
beverages?
If answer is Yes, then ask screening question
about heavy drinking days, such as, How many
times in past year have you had five or more
drinks a day (for men) or four or more drinks a day
(for women)?
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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
To complete a picture of persons drinking pattern, ask,
On average, how many days a week do you have an
alcoholic drink? and On a typical drinking day, how
many drinks do you have?
Recommend person stay at moderate drinking
patterns
Recommend even lower limits or abstinence for
patients who take medications that interact with
alcohol, who have a health condition exacerbated by
alcohol, or who are pregnant (advise abstinence here)
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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
Use brief screening instruments to help identify
problem drinking and those who need more
thorough assessment
AUDIT questionnaire
The AUDIT will help detect less severe alcohol
problems (hazardous and harmful drinking) as well as
alcohol abuse and dependence disorders

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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
AUDIT questionnaire (cont.)
Helpful in emergency department (ED) and trauma patients
because it is sensitive to current alcohol problems
Useful in primary care with adolescents and older adults
Relatively free of gender and cultural bias
AUDIT covers three domains
Alcohol consumption
Drinking behavior or dependence
Adverse consequences from alcohol
The AUDIT-C is shorter form helpful for acute and critical care
units
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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
The CAGE questionnaire (Cutdown, Annoyed,
Guilty, Eye opener)
Works well in primary care settings because it takes
less than 1 minute to complete
The CAGE tests for lifetime alcohol abuse and/or
dependence
Does not clarify past problem drinking from present
Less effective with women and minority groups
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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
Assess for alcohol use disorders using standard
clinical diagnostic criteria
Determine whether there is a maladaptive pattern
of alcohol use causing clinically significant
impairment or distress
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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
Ask, In past 12 months, has your drinking
repeatedly caused or contributed to:
Risk of bodily harm: drinking and driving, operating
machinery, swimming?
Relationship trouble: family or friends?
Role failure: interference with home, work, or school
obligations?
Run-ins with law: arrests or other legal problems?
Ask, In the past 12 months, have you not been
able to stick to drinking limits, or repeatedly gone
over them?
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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
Ask, In past 12 months, has your drinking repeatedly
caused or contributed to:
Shown tolerance: needed to drink more to get same effect?
Shown signs of withdrawal: tremors, sweating, nausea, or
insomnia when trying to quit or cut down?
Kept drinking despite problems: recurrent physical or
psychological problems?
Spent a lot of time drinking or anticipating or recovering?
Spent less time on other matters or activities that had been
important or pleasurable?
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Chapter 6: Substance Use Assessment
Alcohol use (cont.)
Ask about use of illicit substances
Do you sometimes take illicit drugs or street drugs,
such as marijuana, cocaine, hallucinogens, narcotics?
If yes, ask, When was last time you used drugs, and
how much did you take that time?
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Chapter 6: Substance Use Assessment
Screening women for alcohol problems
TWEAK questions help identify at-risk drinking in
women, especially pregnant women
Tolerance: how many drinks can you hold? Or How
many drinks does it take to make you feel high?
Worry: have close friends or relatives complained about
your drinking?
Eye-opener: do you sometimes take a drink in morning
when you first get up?
Amnesia: has a friend or family member told you about
things you said but could not remember?
Kut down: do you sometimes feel need to cut down?
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Chapter 6: Substance Use Assessment
Screening aging adults
Use the SMAST-G questionnaire for older adults
who report social or regular drinking of any
amount of alcohol
Older adults have specific emotional responses
and physical reactions to alcohol and the 10
questions with yes/no responses address these
factors
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Chapter 6: Substance Use Assessment
Advise and assist, brief intervention
Consequences of substance abuse are so debilitating
and destructive to patients and their families that a
short statement of assistance and concern is given
here
If your assessment has determined the patient to have
at-risk drinking or illicit substance use, state your
conclusion and recommendation clearly
You are drinking more than is medically safe.
Relate to the persons concerns and medical findings, if
present; I strongly recommend that you cut down, or quit,
and Im willing to help.
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Chapter 6: Substance Use Assessment
Advise and assist, brief intervention (cont.)
If you determine the person has an alcohol use
disorder, state your conclusion and
recommendation clearly
I believe that you have an alcohol use disorder.
I strongly recommend that you quit drinking, and Im
willing to help.
Relate to the persons concerns and medical findings, if
present
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Chapter 6: Substance Use Assessment
Clinical laboratory findings
These are less sensitive and specific than self-
report questionnaires
Useful data to corroborate subjective data
Serum protein, gamma glutamyl transferase (GGT) is
most commonly used biochemical marker of alcohol
drinking
Occasional alcohol drinking will not raise this measure,
but chronic heavy drinking will
Be aware that nonalcoholic liver disease also can increase
GGT levels in the absence of alcohol
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Chapter 6: Substance Use Assessment
Clinical laboratory findings give objective
evidence of problem drinking (cont.)
From complete blood count, the mean corpuscular volume
(MCV) is an index of red blood cell size
MCV is not sensitive enough to use as only biomarker
Can detect earlier drinking after long period of abstinence
Breath alcohol analysis detects any amount of alcohol in end
of exhaled air following a deep inhalation until all ingested
alcohol is metabolized
This measure can be correlated with blood alcohol
concentration (BAC) and is basis for legal interpretation of
drinking
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