Unlike brief intervention, in-depth substance abuse assessment requires specialized skills and consumes a substantial amount of time -- anywhere from 90 minutes to 2 hours.

As a result, many primary care clinicians will refer patients suspected of having a substance abuse problem to specialists for both assessment and treatment, although clinicians in underserved areas or with expertise in substance abuse may assume partial or total responsibility for this function.

However, even clinicians who will not perform substance abuse assessments should have a basic understanding of their elements and objectives so that they can
Initiate appropriate referrals
Participate effectively as a member of the treatment team, if required
Better fulfill the gatekeepers' monitoring responsibility with respect to patient progress
Carry out needed case management functions as appropriate

Throughout this chapter, assessment will refer to in-depth assessment as distinct from the postscreening brief assessment discussed in Chapter 3.

Assessment Parameters

Substance abuse assessment is the further investigation of patients (1) whose positive screening results indicate that substance abuse is likely and (2) whose responses to the questions in a brief assessment (see Chapter 3) suggest that compulsion to use, impaired control, presence of other psychosocial problems, or absence of social support will render brief intervention ineffective (College of Family Physicians of Canada, 1994).

Information gained through an assessment will clarify the type and extent of the problem and will help determine the appropriate treatment response.

Assessment:

Examines problems related to use (e.g., medical, behavioral, social, and financial)

Provides data for a formal diagnosis of a possible problem

Establishes the severity of an identified problem (i.e., mild, moderate, intermediate, or severe stage)

Helps to determine appropriate level of care

Guides treatment planning (e.g., whether specialized care is needed, components of an appropriate referral, and eligibility for services)

Defines a baseline of the patient's status to which future conditions can be compared (National Institute on Alcohol Abuse and Alcoholism, 1995a)

If one thinks of screening as triage, then assessment is acquiring the information needed to direct a patient to appropriate treatment.

At a minimum, patients must be assessed for:

Acute intoxication and/or withdrawal potential

Biomedical conditions and complications

Emotional/behavioral conditions (e.g., psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, poor impulse control, changes in mental status, or transient neuropsychiatric complications)

Treatment acceptance or resistance

Relapse potential or continued use potential

Recovery/living environment

       (American Society of addiction Medicine, 1996, p. 6)

Assessing along these dimensions helps the assessor confirm that a substance abuse problem exists and recommend an appropriate level of care (see Chapter 5 for a discussion of substance abuse treatment systems and processes).

Through a combination of clinical interview, personal history-taking, and self-reports, supplemented by laboratory testing and collateral reports as appropriate, the assessment process identifies patients' health problems, interest in and readiness for treatment, and feasible treatment options.

It also provides information on a patient's familial, educational, social, and vocational supports and deficits. Like screening, assessment may be a recurring event if clinical evidence indicates the need.

Who Should Assess?

Professional position is less important than specific training for performing accurate assessments. Where possible, the Consensus Panel recommends referring patients to an experienced substance abuse specialist for intensive assessment.

If referral is not possible, the Panel believes that physicians, physician assistants, and advanced practice nurses (nurse practitioners and clinical nurse specialists) with experience in empathic motivational interviewing may perform intensive assessments after receiving training in

The signs and symptoms of substance abuse

The biopsychosocial effects of alcohol and other drugs and likely progression of the disease

Common comorbid conditions and medical consequences of abuse

The terms used in the classification system of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994a), their interpretation, and their relationship to the findings that emerged during the assessment history

The appropriate use, scoring, and interpretation of standardized assessment instruments

Understanding the Impact Of Culture and Gender

Clinicians performing in-depth assessments should also understand how patients' gender and cultural background bear on the characteristics and severity of the disease (Spector, 1996).

For example, more males than females abuse alcohol and drugs, and older women are more likely than older men to abuse prescription drugs.

Culture and gender also may influence patients' recognition of their problems (e.g., local cultural norms may condone or accept male drunkenness) and their reaction to the assessment process and recommended treatment interventions (e.g., substantial stigma may be associated with substance abuse treatment, especially for women and older patients of either sex).

Assessors also should be aware of the influence of their own gender and cultural background on their response to patients with suspected substance abuse problems and on their interpretation of the information provided through the assessment process.

While an understanding of "typical" patterns is useful in anticipating problem areas, experienced assessors resist the temptation to stereotype patients and subsume them within broad categories based on language, ethnicity, age, education, and appearance.

An oft-repeated anecdote illustrating the dangers of stereotyping concerns a well-dressed, middle-aged woman and her disheveled teenage son seen in an emergency room following a car accident. The young man was screened for substance abuse; the mother was not. Several hours after admission, the woman went into alcohol withdrawal.

When referring patients for assessment, primary care clinicians should consider whether a particular patient will relate more readily to a male or female assessor of similar cultural background or if a patient who speaks English as a second language will respond more easily to questions posed in his native tongue (Spector, 1996).

Knowledge of Comorbid Mental Disorders

The relationship between mental disorders and substance use disorders is variable and complicated. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that, in the general population, 4.7 to 13.7 percent of individuals between the ages of 15 and 54 may have both a mental disorder and a substance abuse or dependence problem (Substance Abuse and Mental Health Services Administration, 1995).

Intoxication with a drug can produce psychiatric symptoms that subside with abstinence, but for those with a mental illness, substance use may mask, exacerbate, or be used to ameliorate psychiatric symptoms; precipitate psychological decompensation; or increase the frequency with which individuals require hospitalization.

Because substance abuse disorders often manifest symptoms similar to those of mental health disorders, misdiagnosis may occur.

Inadvertent bias may affect the assessment process when performed by addiction specialists who do not recognize or accept the role of mental disorders in prompting or sustaining substance use or who have no experience with dually diagnosed patients.

Conversely, some mental health practitioners dismiss substance abuse as merely symptomatic of underlying mental health disorders and do not acknowledge it as a problem requiring specific attention.

While screening results, per se, do little to illuminate comorbid mental health disorders, information gleaned through a patient's history or inability to respond to brief intervention may suggest a mental health problem.

If possible, primary care clinicians should refer patients to assessors who understand and are trained in mental health as well as substance abuse assessment and who are willing and able to expand the assessment process as needed to identify the multiple dimensions that may be contributing to a patient's problems (Institute of Medicine, 1990).

Whether referring for or conducting intensive assessments themselves, primary care clinicians also should be alert to the possibility of conflict of interest when assessors are linked to a program or practice providing substance abuse services.

There may be financial incentives (e.g., fee-for-service arrangements) or ideological pressure to interpret assessment results in such a way as to steer patients to a particular program or treatment provider (Institute of Medicine, 1990).

Aside from insisting on an independent assessment source, which may be impractical, clinicians have few options for ensuring objective assessments (Institute of Medicine, 1990).

However, primary care providers who understand the purposes of assessment and are familiar with its components will be in a better position to identify and subsequently avoid biased assessors.

  [continued]

From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians