Norman G. Hoffmann, Ph.D. Western Carolina University

Overriding Principles Clinicians determine diagnoses – assessment instruments don’t Clinicians make decisions – tools don’t Instruments are tools to be used by clinicians to systematically gather information Clinicians should utilize all available information in making determinations including assessment results, legal records, and other corroborating information

Screening vs. Triage vs. Diagnostic Assessment Screening: short, fast, cheap estimate of probability that a person has a condition Triage: brief coverage of all diagnostic criteria to make initial decisions Diagnostic assessment: comprehensive coverage of all diagnostic criteria that when combined with all other sources of information allow clinicians to make a definitive diagnosis

WHEN TO SCREEN? Screen for what is NOT the presenting complaint or problem area. Screen for common problems other than the presenting complaint Addiction programs screen for MH MH clinics screen for addictions Follow with an assessment for the presenting complaint or problem areas identified by positive screen results.

The UNCOPE U – Have you spent more time drinking/using than intended? (Unintended Use) N – Have you ever neglected usual responsibilities because of using? C – Have you ever wanted to cut down on drinking/using? O – Has anyone objected to your drinking/use? P – Have you found yourself thinking a lot about drinking/use? (Preoccupied) E – Have you ever used to relieve emotional distress, such as sadness, anger, or boredom?

UNCOPE: A Brief Free Screen for Substance Use Disorders Six items used in screening adults and adolescents for any substance use disorder Free – from Evince Clinical Assessments [research tab at Two or more positive responses indicate risk for a severe substance use disorder Sensitivity for severe = 90% to 95% Specificity for severe = 90% to 95%

UNCOPE and the DSM-5 The first five UNCOPE items conform to five DSM-5 criteria: Criterion 1: U = unplanned use Criterion 5: N = role fulfillment failure Criterion 2: C = desire to cut down Criterion 6: O = interpersonal conflict Criterion 4: P = craving Item E = possible self-medication – not a DSM-5 criterion

WHEN/WHERE TO TRIAGE? Need more than a screening probability estimate Results: negative finding; severe diagnosis; mild to moderate or unclear When limited time, circumstance, or task precludes a comprehensive assessment Emergency room settings DUI/DWI evaluations Initial inmate evaluation (e.g., jails) Follow with a comprehensive assessment if indicated/required

WHAT IS REQUIRED FOR TRIAGE Cover all of the diagnostic criteria Enable clinicians to exclude a diagnosis based on sufficient negative findings of key markers Confirm obvious diagnoses (especially severe) based on positive criteria findings Provide a concrete summary of positive findings that can be externally reviewed and confirmed by the appropriately trained clinician

WHEN IS A COMPREHENSIVE ASSESSMENT REQUIRED? Treatment intake screens are totally inappropriate and triages may be inconclusive for treatment planning purposes For court dispositions that might require treatment recomendations When litigation may be involved Any situation that requires a potentially life-altering decision

WHAT IS REQUIRED FOR A COMPREHENSIVE ASSESSMENT Thorough coverage of all diagnostic criteria with multiple questions Current and collateral findings regarding problem areas – family, past records, etc. Mechanism for providing a checklist or narrative summary of DSM-5 criteria – a numeric “score” on a “scale” is insufficient – must be based on the specific DSM-5 criteria that are positive

Substance Use Disorder Criteria 1.Use in larger amounts or longer than intended 2.Desire or unsuccessful effort to cut down 3.Great deal of time using or recovering 4.Craving or strong urge to use 5.Role obligation failure 6.Continued use despite social/interpersonal problems 7.Sacrificing activities to use or because of use 8.Use in situations where it is hazardous

DSM-5 SUD Criteria continued 9.Continued use despite knowledge of having a physical or psychological problem caused or exacerbated by use 10.Tolerance 11. Withdrawal Criteria 1-4 relate to use; Criteria 5-8 relate to behavioral issues associated with use; Criteria 9-11 relate to physical/emotional issues

DSM-5 Initial VS. DSM-5 Final Initially the proposed DSM-5 had two diagnostic categories: moderate and severe defined by 2-3 and 4+ positive criteria Final formulation has three categories: mild (2-3), moderate (4-5), and severe (6+ positive criteria) Original “moderate” becomes “mild” No compelling empirical basis for cut points

Pros vs. Cons of theDSM-5 Pros The severe diagnosis identifies people who in all probability need to set abstinence as a goal The mild diagnosis will in most cases be those who do NOT need to have abstinence as a goal Provides a framework for making better treatment decisions based on collection of outcome findings Cons May give the impression that the severe diagnosis is simply a versions of the moderate and mild diagnoses The distinctions between diagnoses are not empirically derived and may not be the optimal points of discrimination

GENDER COMPARISON of DSM-5 ALCOHOL DIAGNOSES Males N = 6,871Females N = 801 Kopak, Metz, & Hoffmann (in press)

GENERAL COMPARISON of DSM-5 CANNABIS DIAGNOSES Males N = 6,871Females N = 801 Kopak, Proctor, & Hoffmann, 2012

GENERAL COMPARISON of DSM-5 COCAINE DIAGNOSES Males N = 6,871 Females N = 801 Proctor, Kopak, & Hoffmann, 2012, in press

COMPARISON of DSM-5 DIAGNOSES FOR ADOLESCENTS Males N = 571 Females N = 333 Malone & Hoffmann, 2012

DSM-5 vs. DSM-IV Summary Almost all who did not get a DSM-IV-TR diagnosis will still not have a DSM-5 diagnosis The vast majority of those with a dependence diagnosis will fall into the severe designation of the DSM-5 Substantial changes will be seen for those now diagnosed with abuse Most will receive a diagnosis of mild substance use disorder A significant minority will no longer get a diagnosis A smaller minority will get a moderate diagnosis

Comparison of TAAD vs. SUDDS-IV DSM-IV Alcohol Diagnoses Males N = 6,871 Females N = 801 SUDDS-IV Diagnosis TAAD Dx

Comparison of TAAD VS. SUDDS-IV DSM-IV Results SUDDS-IV is a longer and more comprehensive assessment (30-45 min.) TAAD is brief (10-15 min.) and is more specific for alcohol All TAAD classifications of dependence are confirmed by SUDDS-IV TAAD may underestimate dependence among abusers

TAAD VS. SUDDS-IV with Initial Alcohol DSM-5 Diagnosis Males N = 6,871 Females N = 801 SUDDS-IV Diagnosis TAAD Dx

Comparison of TAAD VS. SUDDS-IV DSM-5 Results All TAAD moderate to severe confirmed by the longer SUDDS-IV Compared to the DSM-IV results, the TAAD appears to miss more mild diagnoses This may be due to lack of craving and compulsion items on the original TAAD These are added to the TAAD-5 and may resolve this issue

DSM-5 Diagnostic Distribution for First-time DUI/DWI Offenders

Comparison of Diagnostic Results for First-time DUI Offenders DSM-IV-TR Diagnoses N = 658

Distribution of Positive DSM-5 Criteria 45.9% at least mild diagnosis 18.5% at least moderate diagnosis

Other Drug Use Given Alcohol DSM-5 Diagnosis

General DSM-5 Findings Most first-time DUI/DWI offenders will not receive a DSM-5 diagnosis due to: Elimination of legal problems Requirement for two positive criteria The moderate and severe diagnoses conform almost exactly to dependence for almost one in five first-time offenders Positive diagnostic findings for alcohol related to higher probability of drug use

DSM-5 CRITERIA Differentials on Inmate Populations All criteria are not equal in implications Some criteria are found almost exclusively among those in the severe alcohol or other substance use disorder diagnoses Other criteria are more common among the mild to moderate alcohol use disorder group Tolerance and dangerous use are actually common among those with no diagnosis

Distribution of Positive Alcohol Criteria for 6,871 Males DSM-IV Criteria Based on SUDDS-IV Results DSM-5 Designations Pop. Prev. No DxMildMod.Sev. 1. Unplanned use2%8%11%79%27% 2. Unable to cut down<1%4%7%88%21% 3. Time spent using2%6%11%81%28% 4. Craving/compulsion1%3%7%89%21% 5. Role failure<1%3%9%88%25% 6. Social Conflicts3%13%14%70%34%

Distribution of Positive Alcohol Criteria for 6,871 Males DSM-IV Criteria Based on SUDDS-IV Results DSM-5 Designations Pop. Prev. No DxMildMod.Sev. 7. Sacrifice activities<1%2%9%89%23% 8. Dangerous use8%15% 62%36% 9. Contraindications3%10%11%76%30% 10. Tolerance12%11% 66%33% 11. Withdrawal<1%3%7%90%19% Self-medication5%9%11%75%27%

Distribution of Positive Alcohol Criteria for 801 Females DSM-IV Criteria Based on SUDDS-IV Results DSM-5 Designations Pop. Prev. No DxMildMod.Sev. 1. Unplanned use3%8%9%80%31% 2. Unable to cut down0%2%6%92%24% 3. Time spent using0%1%7%92%26% 4. Craving/compulsion<1% 3%96%23% 5. Role failure<1%5% 90%26% 6. Social Conflicts3%10% 77%33%

Distribution of Positive Alcohol Criteria for Females DSM-IV Criteria Based on SUDDS-IV Results DSM-5 Designations Pop. Prev. No DxMildMod.Sev. 7. Sacrifice activities<1%3%4%93%25% 8. Dangerous use6%8%9%77%29% 9. Contraindications3%9%10%78%32% 10. Tolerance10%5%10%75%32% 11. Withdrawal0%2%3%95%20% Self-medication%%%

Positive Alcohol Criterion within DSM-5 Diagnostic Designations DSM-5 Criteria Based on TAAD Results DSM-5 Designations No DxMild Mod.Severe 1. Unplanned use19%72%80%98% 2.Unable to cut down2%14%38%69% 3. Time spent using04%25%62% 4. Craving/compulsion<1%3%12%43% 5. Role failure<1%6%12%74% 6. Conflicts (interpersonal) 3%28%74%90%

Positive Alcohol Criterion within DSM-5 Diagnostic Designations DSM-5 Criteria Based on TAAD Results DSM-5 Designations No DxMild Mod.Severe 7. Sacrifice activities08%22%81% 8. Dangerous use11%43%59%83% 9. Contraindications8%5%17%60% 10. Tolerance13%52%81%86% 11. Withdrawal0%5%12%48% Self-medication3%14%25%61%

SUD Criteria Prevalent in Mod. to Severe – Rare if no Diagnosis The “Big Five” Wanting to cut down/unable to do so Craving with compulsion to use Sacrifice activities to use Failure at role fulfillment due to use Withdrawal symptoms

Clinical Implications of the Differential Criteria Patterns Different populations are consistent in the finding that the “Big Five” are predominately found among the more severely involved Some differences noted for time spent: Female inmates DUI/DWI offenders Population specific interpretations might be required for best clinical results

DSM-5 Criteria Differentials – Is it the Number or the Pattern? All criteria are not equal in implications The pattern of positive criteria findings can suggest differential needs and prognoses Could the diagnostic discriminations based on the number of findings be less important than the pattern of positive results?

Sample of Alcohol Diagnostic Documentation Alcohol DiagnosisDiagnostic Criteria Case 1XXXXXXXX Case 2XXX Case 3XXXXX Case 4XXXXX Severe Mild Moderate Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes

CASE 3: Positive DSM-5 Criteria 3. Great deal of time using 10. Tolerance 1. Unplanned use: more or longer use 8. Use in hazardous situation (impaired driving) 6. Recurrent interpersonal conflicts Conclusions No loss of control indicated Misuse and possible irresponsible behavior Moderation may be a reasonable initial goal

CASE 4: Positive DSM-5 Criteria 4. Craving/compulsion to use 1. Unplanned use: more or longer use 5. Role obligation failures 2. Desire/efforts to cut down 7. Sacrificing activities to use Conclusions Loss of control indicated Positive on 4 of the “Big Five” Abstinence likely required for recovery

Implications for Disposition Education and brief counseling may be appropriate for majority of 1 st time offenders For those with a diagnosis, the pattern may be as important as the number of positive criteria Those positive on any of the Big Five criteria should be carefully evaluated regarding the current and projected trajectory of their condition

Final Criticism of the DSM-IV Loss of control not required for a dependence diagnosis – e.g., tolerance, spending time using, and occasionally drinking more/longer than intended – got the chronic diagnosis Some abuse criteria are stronger indications of a serious condition than some dependence criteria Role obligation failure is a Big Five criterion Tolerance is often seen in mild cases or even among those with no diagnosis

Summary for DSM-5 The TAAD and SUDDS-IV produced similar results for the DSM-IV The TAAD did not approximate the DSM-5 as well necessitating development of the TAAD-5 We expect that the TAAD-5 will better match the results of the SUDDS-5 However, since the TAAD-5 is shorter, it may still underestimate severity in some cases severely affected

Indications of Drug Use Alcohol may not be the only substance of concern with 1 st time offenders Marijuana use most common drug used – about 10% not dependent vs % of dependent (moderate to severe alcohol Dx) Cocaine use unusual for those not dependent on alcohol (severe alcohol use disorder) Use of multiple drugs provides even stronger evidence of probable diagnosis indicating need for abstinence as a treatment goal

General Issues of Validity Validity scales are of limited utility Validity scales themselves may be inaccurate Assessment challenge is to document indications of a substance use disorder Even if some responses are inaccurate, the overall indications might still be accurate Invalidity based on a validity scale does not provide grounds for legal or administrative dispositions

Issues of TAAD-5 Validity Concurrent validity of TAAD with the SUDDS-IV Findings of no diagnosis very likely to be accurate compared to extensive assessment TAAD findings of moderate to severe substance use disorder consistently confirmed by more extensive assessment Some underestimate of severity is likely to persist with the TAAD-5 due to its brevity

TAAD-5 Interpretation Strategy Accept a determination of no diagnosis or severe alcohol use disorder For mild or moderate alcohol use disorder, a relatively small proportion will have a more severe condition – consider further inquiry if there is a questions of severity Multiple positive findings on “Big Five” items with a moderate diagnosis suggests a guarded prognosis with possible emergence of a more serious problem

Referral/Disposition Model Based on empirical evidence Assumes policies and regulations are flexible Uses the diagnostic and assessment findings to drive referral/disposition options Incorporates existing monitoring technologies Motor vehicle interlocks SCRAM (Secure Continuous Remote Alcohol Monitoring) monitors alcohol secretion via an ankle bracelet and reports results via modem Telemetry breathalyzer

Technology Options Vehicle Interlock Verifies that person starting vehicle is not intoxicated Might be defeated with participation of confederates SCRAM Ankle unit monitors level of consumption 24/7 Additional sensors to detect tampering Telemetry breathalyzer Linked to mobile phone for random testing

Ideal World Concepts Some options involve monitoring Clinical findings inform the disposition chosen Monitoring of results can refine the decision processes Disposition decisions utilize all available information – assessment, treatment history (if any), BAC, prior offenses (if any), etc. All options will involve comparable financial costs and time requirements for the offender

Option 1: Moderate-Severe Case SCRAM or breathalyzer monitoring to ensure abstinence during period of supervision Addiction treatment based on ASAM Criteria required for reinstatement Fine (if any) is balance between the treatment recommended and cost of intensive treatment Sanctions for noncompliance or failure to remain abstinent

Option 2: Moderate (no Big Five) Monitoring with SCRAM or breath – no intoxication – OR Interlock Education program regarding drinking & driving plus low intensity treatment if recommended Based on the assumption that some individuals may drink so long as they do not become intoxicated or drive under the influence Fine is equivalent to the cost of addiction treatment minus treatment recommended Sanctions for failure to adhere to protocol

Option 3: Mild or No Clinical Dx Possible monitoring with interlock if desired – assumes moderated use possible Education and brief counseling regarding drinking and driving Based on the assumption that these individuals may drink so long as they do not drive if intoxicated Fine is equivalent to cost of intensive treatment minus the cost of education and counseling Sanctions for failure to adhere to protocol

Assessment Ground Rules for Clinical Practice Rule 1: NO assessment instrument “makes a diagnosis” or a disposition recommendation Rule 2: Assessment instruments provide relevant information to professionals – nothing more Rule 3: Only professionals with the requisite expertise make diagnoses, referrals, or other disposition decisions Rule 4: See Rule 1

Norman G. Hoffmann, Ph.D. Adjunct Professor of Psychology Western Carolina University