Substance Abuse Evaluation

Aka: Substance Abuse Evaluation, Chemical Dependency Evaluation, Illicit Drug

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II. Causes: Common Illicit Drugs

  1. Alcohol Abuse
  2. Sedative-Hypnotics (e.g. Benzodiazepines)
  3. Cannabinoids (e.g. Marijuana, K2, Spice)
  4. Opioids (e.g. Heroin)
  5. Stimulants (e.g. Cocaine, Amphetamines, Bath Salts)
  6. Volatile Inhalants (Sniffing, Huffing, Bagging)
  7. Hallucinogens (LSD, PCP, Ketamine)
  8. Methylenedioxymethamphetamine (MDMA, Ecstasy)
  9. Gamma Hydroxybutyrate (GHB)

III. History: Medical

  1. Excessive habits
    1. Excessive coffee intake
    2. Excessive Tobacco use
    3. Excessive Alcohol use
  2. Exaggerates medical problems
  3. Simulates symptoms
  4. History of frequent injury and emergency care
    1. Trauma
    2. Burn Injury
    3. Fractures
  5. History of unusual infections
    1. Malaria
    2. Tetanus
    3. Hepatitis
  6. Generally debilitated
  7. Chronic disease refractory to medical management
    1. Poorly controlled Diabetes Mellitus
    2. Poorly controlled Hypertension

IV. History: Social

  1. Repeated Driving While Intoxicated (DWI or DUI)
  2. Family History of Chemical Dependency
  3. Problems on the job or at school
    1. Frequent job changes
    2. Tardiness or absence from work
    3. Accidents at work
  4. Family problems
    1. Divorce
    2. Child Abuse or neglect
  5. Changes in friends or relationships
    1. Spending more time with drug and Alcohol users

V. History: Psychiatric

  1. Mood disturbance (Major Depression or Anxiety Disorder)
  2. Suicidal thoughts
  3. Lack of Impulse control
  4. Thought disorders
  5. Sexual Dysfunction
  6. Sleep Disorders

VI. Associated Conditions

  1. Anxiety Disorders
  2. Major Depression
  3. Bipolar Disorder
  4. Post-Traumatic Stress Disorder
  5. Dependent Personality Disorder
  6. Antisocial Personality Disorder
  7. Intimate Partner Violence

VII. Symptoms

  1. Increased Tolerance
  2. Gulping drinks
  3. Preoccupation with drinking
  4. Sneaks substance
  5. Loss of control
  6. Alibis (excuses for substance use)
  7. Avoiding reference (Hiding substance use)
  8. Previously "on the wagon"
  9. Reproof or Confrontation about substance use
  10. Remorse about drinking and consequences
  11. Aggression
  12. Changing Substance use pattern
    1. Avoid consequence
    2. Escaping to other geographic area
  13. Resentments
    1. Blame for the Substance Abuse and consequences
  14. Maintains substance supply (Stashing away a supply)
  15. Prolonged Benders (Staying drunk for a while)
  16. Frequent Blackouts
  17. Attitude changes
    1. Apathy
    2. Blaming
    3. Anger

VIII. Signs

  1. Clinic Calls
    1. Demand to be seen immediately
    2. Usually a late Friday afternoon appointment
    3. Calls or presents after regular clinic hours
  2. Clinic Interaction
    1. Presenting complaints
      1. Low Back Pain
      2. Root canal
      3. Migraine Headache
      4. Ovarian Cysts
      5. Uncontrolled cough ("Needs Codeine")
    2. Demands
      1. Must have a specific Narcotic drug right away
      2. Alternative non-Narcotics are not acceptable
        1. Other medications do not work
        2. Medication allergy
        3. Peptic Ulcer Disease
      3. Lost or stolen prescription
    3. Vague about medical history
      1. Traveling through town or visiting
      2. No primary medical provider
    4. Refuses lab tests or changes test (Blood in Urine)

IX. Signs: Physical findings suggesting Chemical Dependency

  1. General findings
    1. See Toxin Induced Vital Sign Changes
    2. Overt debilitation not related to medical problem
    3. Physical findings out of proportion to complaints
    4. Alcohol odor to breath
      1. Strong odor of mouthwash or after-shave may mask
  2. Eye findings
    1. See Eye Examination Signs of Chemical Dependency
  3. Nasal irritation (due to Cocaine inhalation)
  4. Cardiovascular changes
    1. Labile Hypertension
    2. Tachycardia
  5. Neurologic changes
    1. See Toxin Induced Neurologic Changes
    2. See Altered Level of Consciousness
    3. See Toxin Induced Altered Level of Consciousness Causes
    4. See Toxin-Induced Seizure Causes
    5. Unsteady gait
    6. Slurred speech
    7. Mild Tremor
    8. Inappropriate lapses in conversation
  6. Skin changes
    1. See Skin changes suggestive of chemical dependency

X. Diagnosis

  1. Screening Tools
    1. Drug Abuse Screening Test (DAS-10)
    2. Single-Question Drug Abuse Screening Test (DAS-1)
    3. See Alcoholism Screening
  2. Screen for comorbid conditions
    1. Intimate Partner Violence (>50% Prevalence)
    2. Mood Disorder Screening
      1. Depression Screening
      2. Anxiety Screening
      3. Bipolar Disorder
    3. Post-Traumatic Stress Disorder

XI. Labs: Screening

  1. Urine Toxicology Screening
  2. Findings Suggestive of excessive Alcohol intake
    1. Blood Alcohol (if acute Intoxication suspected)
    2. Serum gamma-glutamyl transpeptidase (GGT) increased
    3. Mean Corpuscular Volume (MCV) increased
    4. Carbohydrate-deficient Transferrin (CDT) increased

XII. Labs: As indicated for comorbid conditions

  1. Urinalysis
  2. Complete Blood Count
  3. Syphilis Serology (VDRL, RPR)
  4. Human Immunodeficiency Virus (HIV Testing)
  5. Viral Hepatitis Screening
  6. Serum Chemistry
    1. Electrolytes with Calcium and Magnesium
    2. Glucose
    3. Renal Function Tests
      1. Blood Urea Nitrogen
      2. Creatinine
  7. Thyroid Stimulating Hormone (TSH)
  8. Stool Guaiac for occult blood

XIII. Management

  1. See Chemical Dependency Brief Counseling
  2. See Substance Abuse Aftercare
  3. See Chemical Dependency Resources

XIV. References

  1. Shapiro (2013) Am Fam Physician 88(2):113-21 [PubMed]
  2. Haverkos (1995) Am Fam Physician 52(7):2029 [PubMed]
  3. Mersy (2003) Am Fam Physician 67(7):1529-32 [PubMed]
  4. Westreich (1995) Postgrad Med 97(4):111-23 [PubMed]

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