There are many screening tools for substance misuse; most are short and easily administered and often involve asking the patient a series of questions. For example, the CAGE questionnaire is a well-known 4-question tool that is quick and easy to use. However, it is more effective for the detection of alcohol misuse. The widely used and validated AUDIT questionnaire is more detailed and is effective for detecting alcohol misuse, but it is also helpful in comparing alcohol use across different countries. There are many more tools available like this, often tailored for a specific substance—for example, the DAST for cannabis misuse. However, none are entirely successful in detecting all types of substance misuse. HONC is a simple tool for assessing nicotine addiction. Even without a specific tool, the essential inquiry should involve asking the patient what substances he has used, how much, and how often, followed by a subjective view of substance use effects on current health and an assessment of patient insight.
A CV will give a patient’s global physical health. Given that substance misuse can affect any part of the body and the varied and complex nature of substance effects, a more focused and specific system approach is often required. This may involve the examination of a particular system in a mental health patient, using the essential inquiry to relate mental symptoms to substance use. For example, a patient with increased anxiety was found to have started using an over-the-counter stimulant. In using these tools, it is essential to understand what constitutes the abuse of a substance and also to realize when assessment is too severe and intrusive, as it may aggravate a mental status.
An isolated single episode of substance use to relieve psychological symptoms is not necessarily harmful to mental health. In some cases, substance misuse may be an appropriate alternative to psychotropic medication. Assessment severity should relate to the potential toxic effects and risks to the patient’s current functioning and future health. Substance misuse should be assessed systematically to reach a primary diagnosis and underlying etiology, as well as the effects on mental and physical health, and then the best possible treatment and prognosis should be considered.
The mental and physical status are equally crucial for a patient, and substance misuse affects both. It can have detrimental effects on mental health, making existing conditions worse and perhaps more complicated to understand as being a result of substance misuse. Thinking of the mind as four domains (mood, cognition, perception, and volition), it is easy to see how altering brain function could impair these areas. For the patient with existing mental health problems, substance misuse can impede recovery. They could misuse substances in an attempt to relieve psychiatric symptoms, worsening the condition and its prognosis.
They may also develop a mental health problem in response to substance misuse or find that their existing problem has become more challenging to manage. With cognition and perception in mind, the effects can be less complex but more damaging to the patient’s well-being. An example of this would be acute anxiety states or panic attacks caused by cannabis use. Delaying cannabis-induced anxiety may only involve cessation of cannabis; however, if left untreated, this could develop into a more chronic anxiety state. For those receiving treatment for severe mental illness or requiring therapy, substance misuse could interfere with the treatment, preventing the acquisition of essential new skills to aid recovery. The consequence to the patient may be the realization that substance misuse has led to his failure to become a functioning member of society, thus further worsening mental health problems. Both mental health and the effects of substance misuse on mental health are better assessed using specific tools.
6.1. Importance of Screening
Clinicians have several justifications for assessing clients as early as possible for the presence of a substance use disorder. The first, undoubtedly, is to understand better the client’s substance involvement and how it may be related to other presenting problems. With a solid knowledge of the severity and complexity of the client’s substance-using behavior and associated issues, a course of treatment can be planned with measurable treatment goals. These goals should be related to the targeted problems and achievable within a specified period.
Another reason for early assessment is to prevent further progression of substance problems or the development of new issues while promoting engagement in treatment and behavioral change. This can be achieved by raising the awareness of the client who minimizes the existence of a substance problem and by providing those clients with a reality check about the consequences experienced and a comparison of their substance use-related goals with the goals of their treatment. Finally, clients are constantly changing, and reassessment provides feedback on client change, which can influence treatment planning and goals. The above reasoning applies to clients with various severity of substance involvement. However, it is essential to note that some clients may have immediate life-threatening consequences of their substance misuse or be in a current state of intoxication or withdrawal.
This may be true for a referral to a treatment conducted in an emergency room or a client who is being seen following a DWI and has been mandated to treatment. In these cases, a quick assessment of the client’s substance use status may precede having to do a more comprehensive evaluation, with the primary goal being to ensure the client’s safety and to determine if the client needs medical intervention.
Assessment Tools
Two types of assessment tools are discussed in this chapter. The first category is quite general and asks questions about the frequency and quantity of substance use, problems related to substance use, and the presence of symptoms that the questionnaire is designed to assess. The second type of assessment is more specific, focusing on a single consequence of drug use. An example is the assessment of depression using a depression rating scale. Such tools are helpful if one is attempting to determine whether a specific intervention affects the severity of the condition being assessed. An initial assessment is essential in determining whether a client has a substance use disorder and the severity of the disorder. This allows the clinician to determine the most appropriate level of treatment. If it is determined that the client’s condition is not severe, the client can be advised to make changes using self-help strategies. Clients with mild to moderate substance use disorders can benefit from outpatient interventions. Those with severe disorders are best advised to seek help from a specialist in substance use treatment and may need a referral to a physician for medical management of their condition.
Evaluating Substance Use Severity
The Global Appraisal of Individual Needs (GAIN) is a comprehensive biopsychosocial evaluation initially developed as a health outcomes measurement tool for adult and adolescent mental health and substance abuse clients. Its purpose is to provide information for treatment planning and outcomes assessment to improve overall societal outcomes for populations with severe needs. The GAIN is a collection of assessments that form a structured individual interview process. It assesses various client needs, including developmental background, physiological condition/devices, cognitive and emotional disorders, behavioral issues, negative behavior patterns, system strength, substance use/addiction, crime, and physical health, computed on a health measure.
The primary motivation to look at the seriousness of substance-impaired people is to coordinate them to the most fitting level of treatment and continuing care. This implies assessing the extent and nature of the patient’s issues is necessary and then matching these assessments to an appropriate intervention. Elucidation of the DSM-IV substance misuse and dependence measures has already begun to provide such a proper guideline. To fully address severity evaluation requires a system to identify and classify many potential customer needs. Evaluation is an ongoing process, with the assessment of goals and the impact of intervention on severity being essential.