Alcoholism, Substance Abuse and Dependency > Chapter 5 - Diagnostic Tools
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Diagnostic Tools

If a client is being treated for some other mood, psychological, or character disorder, and it is determined that they are also using substances at a level that meets diagnosable criteria, then there is a “Dual Diagnosis” made. When performing a thorough psychosocial assessment questions regarding the client’s possible drug use will be explored. It is important to know what prescribed medications the person may be using, in addition to the abuse or dependence of those drugs, or other drugs that are illegal. It would be nearly useless to treat or address problems the client may be having (problems doing their job, completing school assignments, conflicted relationships, or emotional problems) if they are concurrently abusing drugs. If the client is using drugs the use itself is either creating or exacerbating the other problems they are experiencing. In order to have reasonable success you must have the client “with you,” but if they are intoxicated, they cannot be. Even when the drug use may have been a reaction to a different problem, the drug use still needs to stop for interventions on other problems to be successful. In other words, until the substance abuse problem is addressed, progress with the other areas of therapeutic concern will be minimal.

For this reason, identifying substance abuse and dependence, if they exist, is a key to successful treatment. After identifying that there is a use of substance involved, the severity of the use is then diagnosed, along with the psychosocial influences that contribute to the use.


[Qn.No.59. Identifying substance abuse and dependence, if they exist, is a key to successful treatment.True or False?]

A. DSM-5 Diagnostic Criteria of Substance Use Disorders

The following excerpts from the DSM 5 provide current guidelines/crtieria for the diagnosis of some substance related and addictive disorders. This is not include all of the mentioned disorders found in the DSM 5, and for complete diagnosis , the DSM 5 should be consulted.

The substance disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or similarly acting arylcyclohexylamines] and other hallucinogens); inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances. These 10 classes are not fully distinct. All drugs that are taken in excess have in common direct activation of the brain reward system, which is involved in the reinforcement of behaviors and the production of memories. They produce such an intense activation of the reward system that normal activities may be neglected. Instead of achieving reward system activation through adaptive behaviors, drugs of abuse directly activate the reward pathways. The pharmacological mechanisms by which each class of drugs produces reward are different, but the drugs typically activate the system and produce feelings of pleasure, often referredto as a ''high." Furthermore, individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.


[Qn.No.60.Drugs that are taken in excess have in common the direct activation of :]

Alcohol Use Disorder

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
  • Alcohol is often taken in larger amounts or over a longer period than was intended.

  • There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

  • A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recovôr from its effects.

  • Craving, or a strong desire or urge to use alcohol.

  • Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

  • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

  • Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

  • Recurrent alcohol use in situations in which it is physically hazardous.

  • Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

  • Tolerance, as defined by either of the following:

    • a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

    • b. A markedly diminished effect with continued use of the same amount of alcohol.

  • Withdrawal, as manifested by either of the following:

    • a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499-500).

    • b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
    • (DSM V, pp. 491-92)

Cannabis Use Disorder

Diagnostic Criteria A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
  • Cannabis is often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.
  • A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.
  • Craving, or a strong desire or urge to use cannabis.
  • Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home.
  • Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.
  • Important social, occupational, or recreational activities are given up or reduced because of cannabis use.
  • Recurrent cannabis use in situations in which it is physically hazardous.
  • Cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis.
  • Tolerance, as defined by either of the following:
    • a. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect.
    • b. Markedly diminished effect with continued use of the same amount of cannabis.
  • Withdrawal, as manifested by either of the following:
    • a. The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal, pp. 517-518). [Refer to DSM 5]
    • b. Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Opioid Use Disorder

Diagnostic Criteria A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
  • Opioids are often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
  • A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  • Craving, or a strong desire or urge to use opioids.
  • Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
  • Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  • Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  • Recurrent opioid use in situations in which it is physically hazardous.
  • Continued opioid 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.
  • Tolerance, as defined by either of the following:
    • a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
    • b. A markedly diminished effect with continued use of the same amount of an opioid.

    Note: This criterion is not considered to be met for those taking opioids solely underappropriate medical supervision.
  • Withdrawal, as manifested by either of the following:
    • a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal, pp. 547-548).
    • b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

    Note: This criterion is not considered to be met for those individuals taking opioidssolely under appropriate medical supervision.

Stimulant Use Disorder

Diagnostic Criteria A pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
  • The stimulant is often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control stimulant use.
  • A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant, or recover from its effects.
  • Craving, or a strong desire or urge to use the stimulant.
  • Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home.
  • Continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant.
  • Important social, occupational, or recreational activities
    • are given up or reduced because of stimulant use.
  • Recurrent stimulant use in situations in which it is physically hazardous.
  • Stimulant use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the stimulant.
  • Tolerance, as defined by either of the following:
    • a. A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect.
    • b. A markedly diminished effect with continued use of the same amount of the stimulant.

      • Note: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention- deficit/hyperactivity disorder or narcolepsy.
  • Withdrawal, as manifested by either of the following:
    • a. The characteristic withdrawal syndrome for the stimulant (refer to Criteria A and B of the criteria set for stimulant withdrawal, p. 569).
    • b. The stimulant (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

      • Note: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy.

    There are diagnostic tools and questions that a practitioner may use in assessing drug and alcohol use.
    The following four questions were developed by the American Psychiatric Association as an initial quick assessment to determine if alcohol use needs to be explored further in treatment:

B. CAGE Questionnaire

Have you ever felt you should cut down on your drinking?

Have people annoyed you by criticizing your drinking?

Have you ever felt bad or guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Scoring:

Item responses on the CAGE are scored 0 or 1; with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. (NIAAA, 2002)


[Qn.No.61. The CAGE score indicates alcohol problems if the total score is:]

C. Alcohol Screening Test

Another test that can be used to assess the level of alcohol use and dependence further is available online. This system uses a point system based on the answers to 25 questions. Examples of questions include: “Have you gotten info fights when drinking?”, “Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?” and “Have you ever been told you have liver trouble?” This test can be taken online and seen at this link:

http://alcoholism.about.com/od/problem/a/blquiz1.htm

D. PDFA Assessment

The Partnership for a Drug-Free America also provides self-assessment tests that can be used by practitioners to assess the level of substance abuse by a client. These questions include: “Are you unable to stop using drugs when you want to?”, “Do your spouse or parents ever complain about your involvement with drugs?”, and “Have you engaged in illegal activities in order to obtain drugs.” The link to this and other screening tests is here: http://www.drugfree.org/Intervention/Assessing/

In addition, the “Partnership” provides other useful resources including information for local treatment centers. There is also helpful information available to those who have loved ones or friends who may be using drugs or abusing alcohol, and tips to help them.

The tests mentioned, and others like them, assist the healthcare practitioner and the client to view through objective and measurable ways how the use of alcohol may be adversely affecting the client’s life. As in most problem-solving, the first step is to accept that there is a problem.

In addition to assessment through questioning, the trained and informed healthcare professional can detect substance abuse through the observation of behaviors and physical symptoms. These symptoms are addressed more specifically for each drug in the table at the beginning of the course and there is no sense in being repetitive here. It is, however, important to not conclude that every presenting symptom is a sign that someone is using drugs. There are other circumstances that may cause behavioral and physical symptoms to appear that are independent of drug use. For example, a client could reasonably come in after working an overnight shift, presenting drowsiness, difficulty focusing and maybe anxiety if things were tense at work. These represent symptoms of multiple drugs.
 
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