Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Substance Use Assessment Chapter 6

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Alcohol Use and Abuse  Alcohol  Most used and abused psychoactive drug  Given rates of alcohol use, it is not surprising that 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 Alcohol is involved in 40% of 41,000 annual deaths due to traffic accidents Slide 6-2

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Alcohol Use and Abuse(cont.) Alcohol Use and Abuse (cont.)  Alcohol (cont.)  Emergency department 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: 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 Slide 6-3

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Alcohol Use and Abuse(cont.) Alcohol Use and Abuse (cont.)  Alcohol (cont.)  In 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 Slide 6-4

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Alcohol Use and Abuse(cont.) Alcohol Use and Abuse (cont.)  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 Slide 6-5

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Defining Illicit Drug Use  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 Marijuana was most commonly used illicit drug with 6.1% of persons aged 12 or older reporting past month use Slide 6-6

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Defining Illicit Drug Use(cont.) Defining Illicit Drug Use (cont.)  Illicit drug use has 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 Oxycodone Hydrocodone Hydrocodone Methadone Methadone Slide 6-7

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Diagnosing Substance Abuse  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 that is not curable but is highly treatable  Accurate diagnosis needed for advice, intervention, appropriate treatment, and follow-up Slide 6-8

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Diagnosing Substance Abuse(cont.) Diagnosing Substance Abuse (cont.)  Gold standard of diagnosis is well defined in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)  Alcohol problems under-diagnosed both in primary care settings and in hospitals  Excessive alcohol use often unrecognized until patients develop serious complications Slide 6-9

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Developmental Competence  Pregnant woman  Among pregnant women 15 to 44 About 10.6% report current alcohol use About 10.6% report current alcohol use 4.5% reporting binge drinking and 4.5% reporting binge drinking and 0.8% reporting heavy drinking 0.8% reporting heavy drinking No amount of alcohol has been determined safe for pregnant women No amount of alcohol has been determined safe for pregnant women Potential adverse consequences of alcohol use to fetus are well known 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 All women who are contemplating pregnancy or who are pregnant should be screened for alcohol use, and abstinence should be recommended Slide 6-10

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Developmental Competence(cont.) Developmental Competence (cont.)  Aging adult  Prevalence of current alcohol use decreases with increasing age 67.4% among those 26 to % among those 26 to % among those 60 to % among those 60 to % among those 65 or older 39.7% among those 65 or older Slide 6-11

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Developmental Competence(cont.) Developmental Competence (cont.)  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 Liver metabolism and kidney functioning decreases, increase availability of alcohol in blood for longer periods Less tissue mass means increased alcohol concentration in blood 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 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 Drinking alcohol increases risk of falls, depression, and gastrointestinal problems Slide 6-12

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data  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 Slide 6-13

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  Alcohol use  Ask about alcohol use Do you sometimes drink beer, wine, or other alcoholic beverages? 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)?” Slide 6-14

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  Alcohol use (cont.)  To complete a picture of person’s 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) Slide 6-15

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  Alcohol use (cont.)  Use brief screening instruments to help identify problem drinking and those who need more thorough assessment  AUDIT questionnaire A quantitative form that has the advantage of letting the examiner document a number for a response so it is not open to individual interpretation A quantitative form that has the advantage of letting the examiner document a number for a response so it is not open to individual interpretation The AUDIT will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders The AUDIT will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders Slide 6-16

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  Alcohol use (cont.)  AUDIT questionnaire (cont.) Helpful with emergency department (ED) and trauma patients because it is sensitive to current, as opposed to past alcohol problems Helpful with emergency department (ED) and trauma patients because it is sensitive to current, as opposed to past alcohol problems Useful in primary care with adolescents and older adults Useful in primary care with adolescents and older adults Relatively free of gender and cultural bias Relatively free of gender and cultural bias  Note that AUDIT covers three domains Alcohol consumption Alcohol consumption Drinking behavior or dependence Drinking behavior or dependence Adverse consequences from alcohol Adverse consequences from alcohol  The AUDIT-C is shorter form helpful for acute and critical care units Slide 6-17

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  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 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 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 Slide 6-18

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  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 Slide 6-19

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  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? Risk of bodily harm: drinking and driving, operating machinery, swimming? Relationship trouble: family or friends? Relationship trouble: family or friends? Role failure: interference with home, work, or school obligations? Role failure: interference with home, work, or school obligations? Run-ins with law: arrests or other legal problems?” 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?” Slide 6-20

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  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 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? 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? Kept drinking despite problems: recurrent physical or psychological problems? Spent a lot of time drinking or anticipating or recovering? Spent a lot of time drinking or anticipating or recovering? Spent less time on other matters or activities that had been important or pleasurable?” Spent less time on other matters or activities that had been important or pleasurable?” Slide 6-21

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  Alcohol use (cont.)  Ask about use of illicit substances “Do you sometimes take illicit drugs or street drugs, such as marijuana, cocaine, hallucinogens, narcotics?” “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?” If yes, ask, “When was last time you used drugs, and how much did you take that time?” Slide 6-22

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  Screening women for alcohol problems  The 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? 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? 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? 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? 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? Kut down: do you sometimes feel need to cut down? Slide 6-23

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  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 Slide 6-24

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  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.” “You are drinking more than is medically safe.” Relate to the person’s concerns and medical findings, if present; “I strongly recommend that you cut down, or quit, and I’m willing to help.” Relate to the person’s concerns and medical findings, if present; “I strongly recommend that you cut down, or quit, and I’m willing to help.” Slide 6-25

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Subjective Data(cont.) Subjective Data (cont.)  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 believe that you have an alcohol use disorder.” “I strongly recommend that you quit drinking, and I’m willing to help.” “I strongly recommend that you quit drinking, and I’m willing to help.”  Relate to the person’s concerns and medical findings, if present Slide 6-26

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Objective Data  Clinical laboratory findings give objective evidence of problem drinking  These are less sensitive and specific than self- report questionnaires Useful data to corroborate subjective data Useful data to corroborate subjective data Serum protein, gamma glutamyl transferase (GGT) is most commonly used biochemical marker of alcohol drinking 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 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 Slide 6-27

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 6: Substance Use Assessment Objective Data(cont.) Objective Data (cont.)  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 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 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 This measure can be correlated with blood alcohol concentration (BAC) and is basis for legal interpretation of drinking Slide 6-28