Clinical Assessment for

Substance Use Disorder

 History
PE
some already covered in intoxication/withdrawal
MSE
Laboratory and other data
 Barriers to honest disclosure
by patients
Pragmatic action to avoid possible
consequences
Discomfort
Shame
Fear
Distrust
Hopelessness
 Attitude
Collaborative partnership- not confrontational
Honest, genuine
Respectful
Matter-of-fact
Non-judgmental
Supportive: Empathic and compassionate
Reflective
Patient-centered
Components of a thorough history
History of substance use
History of substance use disorder
Family history
Relevant psychiatric history
Relevant medical/surgical history
Relevant psychosocial history
 Substance use history
Substance type
Illicit
Prescribed
OTC , supplements, internet
mode of onset, quantity, frequency, and duration of
substance
most recent use: dose, how long ago
typical combinations used
pattern of use
motivation for use and desired effect;
specific circumstances (e.g., where, with whom, how
much)
 SUD history
Pattern of use over time dose escalation, increased
time
Efforts to reduce, control or stop
Abstinence
What supported abstinence
Relapse
Treatment
Attitude toward treatment
Preferences, motivations
Barriers to treatment
Types of treatment
Impression of benefit or harm
 SUD history (continued)
Consequences
Role function eg work, parenting
relationships
DUI and legal
Financial
Psychiatric symptoms or disorders
Medical symptoms or conditions
 Additional relevant history
Family history of SUD
Relevant psychiatric history
Relevant medical history including pain
Psychosocial history
Substance use in the home, school years, peers,
workplace or colleagues
Beliefs or practices: religious or cultural
Current roommates, supports, community
Sample language
 Physical Exam
Signs during intoxication/withdrawal
See chart
 Data for SUD
Toxicology data
Other Lab data
PMP Prescription Monitoring Program
Pharmacy data
 Toxicology lab data
Tests vary based on threshold of detection
E.g. toxic levels of BZ vs therapeutic levels
Dilute urine leads to lower levels
Limited screens vs Comprehensive toxicological
analysis
Elimination half-life of drug/metabolite measured
determines the window of detection
Serum ~ 12 hours, urine 1-3days
Cocaine window is as little as 24 hours
Heavy cannabis use: positive UDS for up to a month
 Drug Screens
Enzyme immunoassay initial screen
GC-MS for more definitive testing

Urine typically for opioids, cocaine, cannabis,

BZ

Serum useful to measure level of potentially

fatal substances: Alcohol blood level
 Urine drug screens for opioids
Opiate positive: morphine derivatives
Heroin, morphine
Often synthetic opioids may
Know what your hospitals UDS tests for
Request methadone, oxycodone, fentanyl,
buprenorphine specifically
 PMP data:
Prescription Monitoring Program
Massachusetts online Prescription drug
monitoring program
Record of schedule II III controlled
substances prescriptions
Stimulants, benzodiazepines, opioids
Date, dose, # pills, pharmacy, prescribing doctor
Paid out of pocket
System upgrade this summer
 Pharmacy data
Pharmacy can give you more recent
information than PMP
Current medications taken by a pt in ED
How many refills remain
Prescribing doctor
 References
APA Practice Guideline for the Treatment of
Patients with Substance Use Disorders, 2nd ed,
2010.
American Psychiatric Press Textbook of
Substance Abuse Treatment, 5th ed, 2015.
Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid
Addiction Patient Assessment. SAMHSA
2004.