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, , SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS and provides a guide to the severity and extent of the problems Psychiatric Association (American Psychiatric Association, associated with substance use. This will inform what diagnosis 2013). In DSM V ”dependence” and “abuse” diagnoses are or diagnoses can be made and which in turn will inform the combined them into “substance use disorder” which has treatment package. been expanded to include gambling disorder. Criteria for Substance Use Disorder (DSM-V) and Harmful 2. ICD 10: International Classification of Diseases (WHO, 1994) Use and Dependence (ICD10) and this this is currently being revised for version 11. There are currently two systems of classification used to diagnose conditions associated with substance use: 1. DSM V: Diagnostic and Statistical Manual of the American
DSM V ICD 10 The presence of at least 2 of these symptoms indicates Substance Harmful use: A pattern of psychoactive substance use that is causing Use Disorder (SUD). The severity of the SUD is defined as: damage to health; the damage may be to physical or mental health Mild: the presence of 2 to 3 symptoms Dependence: Diagnosis of a dependence should be made if three or Moderate: the presence of 4 to 5 symptoms more of the following have been experienced or exhibited at some Severe: the presence of 6 or more symptoms time during the last year The substance is often taken in larger amounts or over longer A strong desire or sense of compulsion to take the substance 1 period than was intended 2 There is a persistent desire or unsuccessful efforts to cut down Difficulties in controlling substance-taking behaviour in terms of its or control substance use onset, termination, or levels of use A great deal of time is spent in activities necessary to obtain Physiological withdrawal state when substance use has ceased or substances, use substances, or recover from their effects been reduced, as evidenced by either of the following: the 3 characteristic withdrawal syndrome for the substance of use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms Craving, or a strong desire or urge to use a substance(s) Evidence of tolerance, such that increased doses of the psychoactive 4 This is new to DSM V substance are required in order to achieve effects originally produced by lower doses
Recurrent substance use resulting in a failure to fulfil major role Progressive neglect of alternative pleasures or interests because of 5 obligations at work, school or home psychoactive substance use and increased amount of time necessary to obtain or take the substance or to recover from its effects Continued substance use despite having persistent recurrent Persisting with substance use despite clear evidence of overly 6 social or interpersonal problems caused or exacerbated by the harmful consequences (physical or mental) effects of the substance Important social, occupational, or recreational activities are 7 given up or reduced because of substance use Recurrent substance use in situations in which it is physically 8 hazardous Substance use is continued despite knowledge of having had a 9 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 amount of substance to achieve intoxication or desired effect or markedly diminished 10 effect b) A markedly diminished effect with continued use of the same amount of substance Withdrawal, as manifested by either of the following: 11 a) The characteristic withdrawal syndrome for substance use b) A substance is taken to relieve or avoid withdrawal symptoms
2 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
3.2 Comprehensive history taking The assessment process will include This section is the protocol for history taking as part of l Initial screening (presenting problem, current substance assessment use, risk assessment including mental state and any The key principle underlying an assessment is to determine the safeguarding issues, confidentiality and consent) nature and extent of substance use and the interaction of use l Comprehensive history as outlined below and psychological and physical symptomatology. l Physical and mental state examination
Every patient should be assessed for substance use. It is l Biological testing important to emphasise that the style of questioning, i.e. that it l Use of appropriate tools to monitor pattern of substance should be non-judgmental, non-confrontational, and should be use, estimation of problems associated with substance use seen as part of engagement – the start - of the treatment and assessment of dependence and degree of process. It is important if feasible to build a relationship with the dependence patient prior to administering assessment tools too rapidly. The table below highlights the schedule of areas to be covered Much depends on the context of the initial consultation or in a comprehensive assessment. meeting. Avoidance of stereotyping is central to this process. Comprehensive protocol for history taking Area of questioning Questions to ask
Substance use l Age of initiation: first tried each substance Ask the same questions for each substance l Age of onset of weekend use in turn l Age of onset of weekly use l Alcohol l Age of onset of daily use l Amphetamines l Pattern of use during each day i.e. quantity/weight, frequency l Benzodiazepines l Route of use e.g. oral, smoking, snorting, intramuscular, intravenous, l Cannabis subcutaneous (“skin popping”) l Cocaine l Age of onset of specific withdrawal symptoms and dependence syndrome l Ecstasy features (see classification above) l Heroin and other opiates l Current use over previous day, week, month l “Legal Highs” l Number of days of abstinence (reasons for this) l Methadone l Current cost of use l Nicotine l Maximum use ever l Over the counter medication l How substance use is funded l Prescribed medication l Source of substances l Solvents l Periods of abstinence l Any other drugs bought over the l Triggers to relapse internet l Preferred substance(s) and reasons l If injecting, current injection sites, previous injection sites, any problems with these.
Treatment episodes l Dates, length of contact with service l Type of services, and what was provided/types of interventions l The outcome of each contact, what was achieved, did patient view it as successful or otherwise l What was the reason to discontinue with the service l Triggers to relapse, reasons to make contact with the service again
Family history l Parents, siblings, grandparents, aunts, uncles, wife, husband, partner, children l History of substance use within the family members mentioned and any related problems l History of psychiatric problems e.g. suicide, self-harm, depression, anxiety, psychotic illness l History of physical health problems l Separation, divorce, death l Family relationships, conflict , support l Occupational history l Whether childhood spent with biological parents or others l Friends and other support networks
3 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
Area of questioning Questions to ask
Living arrangements l Current living arrangements – e.g. home, hostel, care home l With spouse, partner, family, friends, alone l Cared for/carer l Permanent, temporary l Social network l Future plans l Housing support needs l Benefits l Any concerns of vulnerability? Such as victim of a pimp or drug dealer, domestic violence
Life style issues l General physical state l Sleep, diet , weight l Injecting practices including risk to others l Wound management l Oral health l Vaccination history l History of breast, cervical cancer screening l Sexual health issues l Other health issues
Medical history l Past history – chronic conditions l Current diagnosis, medications, treatment l Episodes of acute or chronic illnesses: respiratory, infective, HIV, tuberculosis, cardiovascular, hepatitis, injury, accidents, surgery, overdose, disability – and whether any of these are related to substance use l Any screening for blood borne viruses (hepatitis B, C and HIV), dates and outcomes l Admission to hospital, dates, problems, treatment, length of admission and outcome l Current GP, care, condition(s), treatments
Psychiatric history l Past history l Current signs and symptoms l Risk assessment l Current diagnosis, medication l Assessment by GP for “minor” complaints such as anxiety, depression l Treatment by GP with psychoactive drugs l Referral to specialist psychiatric services for assessment and treatment, dates, reasons, diagnosis, outcome l Any mental health act assessments l History of self-harm and family history of self-harm and suicide
Personal history l Developmental milestones, occupational, sexual, marital, relationships, maturity l Pregnancy/infertility/trying to conceive
Educational History l Age started and left school l Any truancy or difficulties at school e.g. bullying, abuse l School achievements and aspirations l Apprenticeships l University or other higher education
Criminal history l Involvement in criminal activities, both related and non-related to substance use l Age in first contact with the criminal justice system and reasons l Cautions, charges, convictions
4 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
Area of questioning Questions to ask
l Types of activity, shoplifting, theft, prostitution l Imprisonment at any time in Young offenders institution or prison l Any current issues
Vocational and social function l Employment, training or education after school – past and current l Types of work l Ongoing activities and plans l Skills l Retirement l Volunteering l Leisure/hobbies
Social background l Ethnicity and cultural background l Religious and spiritual beliefs
Financial status l Any current problems that may require support from an adviser such as debts, benefits issues,
Biological measures l Biochemistry: alcohol levels, drug screens l Virology
Contact with other services l Child protection history (current and previous) l Child abuse/neglect l Vulnerable adult l Other social services involvement
Risk factors l Social isolation l Recent losses l History of harm to self and others
Further information l Carers, family, friends l Other service provider
Perspective of patient l Perception of problems l Motivation for change – strengths, barriers, support
(Source: adapted from: Crome and Ghodse, 2007) 3.3 Obtaining information from others including medical emergencies, neurological deficits, infectious In addition to taking a full assessment, it is useful to obtain diseases, states of withdrawal and intoxication, and cardio- information for others to assist in building up an accurate respiratory disorders to mention a few. It is useful to record on a picture and to also clarify any ambiguity. This may include some diagram the location of observations of the impact of substance of the following: use on the patient, such as track marks from injecting, or abscesses, scars from previous abscesses. This enables l Family members and friends identification of the impact that substance use has on all l Colleagues systems and all parts of the body, including location of track l Carers marks, abscesses, or other injection sites. l Other professionals e.g. GPs, other specialists, social 3.5 Mental health examination workers, probation officers, pharmacists It is important to distinguish between substance-induced and l In the case of young people (school, college, tutors) substance related psychiatric disorders. The key elements of the This may particularly important in relation to patients who are mental state examination should include: unconscious, have a memory loss, or where English is not the l Attitude to the interview first language. Also special consideration needs to be given for l Appearance and behaviour older people, who may not be able to recall information or who l Speech are not able to provide an accurate account. l Mood 3.4 Physical examination and recording A physical examination should be conducted to assess medical l Thought processes including suicidal ideas, illnesses. This will include a wide range of medical conditions plans and intentions
5 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
l Delusions To perform a drug test on someone's urine, a sample has to be l Perceptual disturbances collected in an examination cup, (often in a controlled environment). For immediate results, the test is performed with l Cognition a dip stick, but for most sophisticated results, the urine is sent l Judgement and capacity to consent to treatment out to a testing facility for immunoassay or gas chromatography l Insight and the results are given after a week or two. 3.6 Investigations and tests Hair tests do not measure current use, but rather non- Substances can be tested in blood, urine, hair, saliva and breath. psychoactive residues that remain in the hair for months Blood tests are a better detector of recent use, since they afterwards. These residues are absorbed internally and do not measure the actual presence of substance in the system. appear in the hair until 7-10 days after first use. These are not Because they are invasive and difficult to administer, blood tests commonly used in the UK except for research purposes. are used less frequently. They are typically used in investigations Saliva testing is also used in the detection of substances in of accidents, injuries or incidents where they can give a useful specialist drug clinics. They detect secretions from inside the indication of whether the subject was actually under the oral tissues that cannot be washed out with mouthwash. influence of substances. Breathalyser: it is not always possible to detect alcohol use on the breath, and therefore it is useful to invite the patient to blow into a breathalyser (alcometer) as an effective way of measuring blood alcohol levels Substance type Detection period in urine drug Urine tests are widely used for assessment of drugs in the screening (maximum range) system. A positive result is not a sign of dependence, but an Cocaine 12-72 hours indication that the drug has been taken. It is important to note that it is not uncommon for a patient to provide a fake Amphetamines 2-4 days specimen knowing what the result will be, for example if Heroin 2-4 days someone wants to ensure there is a negative test due to being Codeine 2-4 days in an accident where their substance use may be demonstrated. Where the patient is drug seeking and looking for drugs to be Cannabis (casual use) 2-4 days prescribed, they will want to provide a positive test result. These Cannabis (chronic use) 30 days may be provided by others (a fake test). Dip stick tests are a Diazepam 30 days useful way to check substance use in urine as part of overall assessment, but this result alone should not be relied upon. A number of blood tests are used for detection of the effects of alcohol:
Gamma Glutamyl Transferase (GGT) Often elevated before liver damage has occurred due to alcohol induced enzyme induction. At higher readings damage more likely Alanine Transaminase (ALT) When raised it is more suggestive of hepatocellular injury Aspartate Transaminase (AST) AST:ALT ratio of more than 2 in the presence of liver disease suggests alcohol related liver damage Alkaline Phosphatase Raised in hepatitis with biliary duct obstruction Bilirubin Individuals may be jaundiced if elevated Albumin Low albumin can reflect acute hepatitis or cirrhosis Triglycerides Raised in early stages of fatty liver infiltration before hepatitis develops Uric acid Metabolism of alcohol results in acidosis, a build up of urates and possibly gout Amylase Raised in pancreatitis Mean Cell Volume (MCV) If raised check B12 and folate levels, which may also be deficient due to alcohol misuse Platelet count Low count may reflect bone marrow toxicity Haemoglobin Anaemia may be due to poor nutrition, vitamin deficiencies or bleeding from ulcers White Blood Count Reduced in bone marrow toxicity and raised in infection, hepatitis and pancreatitis
6 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
4.0 Tools l Problems associated with substance use especially risk There are a range of tools available for the screening of drug and behaviour alcohol use (see table). l Dependence and degree of dependence
Assessment tools are often used to help guide and structure l Health, social and economic circumstances dialogue between professional and patient. When used in the 4.1 Screening tools assessment of substance misusers, they commonly collect There are a range of screening tools designed to assist in information on the: detection of an alcohol or drug problem, a selection of these can l Changing pattern of substance use be found in the table below. (tobacco, alcohol, drugs)
Tool Description of tool Link The AUDIT Detects hazardous and harmful drinking http://www.alcohollearningcentre.org.uk/topics/Browse/Briefadvice/ (Alcohol Use Disorders 10 items in 3 sub groups ?parent=4444&child=4896 Identification Test) 2 minutes to complete AUDIT C Brief Screens for alcohol use http://www.alcohollearningcentre.org.uk/topics/Browse/Briefadvice/ Assesses level of risk of drinking patterns ?parent=4444&child=4898 3 questions FAST Screening for alcohol use http://www.alcohollearningcentre.org.uk/topics/Browse/Briefadvice/?par (Fast Alcoholic Relevant to screening in A&E ent=4444&child=4570 Screening Test) 4 questions, can be self administered or completed by a staff member Takes about 30 seconds to complete DAST Screening for drug use http://www.drtepp.com/pdf/substance_abuse.pdf (Drug Abuse Long version is a 28 item tool Screening Test) To identify problems associated with drug use DAST 10 Screening for drug use http://www.psychcongress.com/saundras-corner/scales- Shorter version 10 items screeners/suds/drug.use.questionnaire-dast-10 To identify problems associated with drug use in adults, and takes 5-10 minutes PAT Evolved over 15 years as a clinical tool to facilitate www.alcohollearning.centre.org.uk/topics/Browse/Hospital/ (Paddington Alcohol emergency doctors and nurses giving brief emergencyMedicine/? Test) advice. Detect alcohol use FIVE SHOT Questionnaire on heavy drinking http://www.alcoholism.about.com/od/test/a/fiveshot.htm MAST Screening for alcohol with a shorter one http://sbirt.vermont.gov/screening-forms/older-adult-alcohol-screening- S-MAST-G specifically designed to be used when screening instrument/ Geriatric Version older people CRAFFT Screens adolescents for high risk alcohol and http://www.ceasar-boston.org/Clinicians/crafft.php other drug use disorders This is a short, self-administered behavioural health screening tool developed specifically for young people CAGE The CAGE is a brief 4-item screen for alcohol use, http://patient.info/doctor/cage-questionnaire and can be undertaken on 1 minute. http://www.partnersagainstpain.com/printouts/a7012Da4.pdf
CAGEAID The CAGEAID (adapted to Include Drugs) has www.sbirttraining.com/node/535 been developed for screening drug use disorders. Can be used in adults, adolescents, inpatients of general medical hospitals and clients with schizophrenia Fagerstrom Screening for nicotine dependence http://ndrXurtin.edu.au/btitp/documents/Fagerstrom_test.pdf A six point questionnaire, that takes 2 minutes to compete.
See appendix for screening tools 7 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
4.2 Assessment Tools There are a wide range of assessment tools used in undertaking a more comprehensive assessment for a range of objectives e.g. severity of dependence, treatment needs and monitoring, some of which are listed below.
Opiate treatment Index Reflects all aspects of treatment including http://ndarc.med.unsw.edu.au/resources/opiate-treatment-index-oti- (OTI) drug use, HIV risk-taking behaviour, social manual functioning, criminality, health status and psychological adjustment. Most suitable for use in specialist substance misuse services SADQ (Severity of The SADQ is a short, self-administered, 20- http://www.alcohollearningcentre.org.uk/topics/Latest/resource/?cid= Alcohol Dependence item questionnaire designed by the World 4615 Questionnaire) Health Organisation to measure severity of dependence on alcohol. Self-complete by the patient, takes 5 minutes, it takes 1 minute for a staff member trained in its use to score. The Severity of The Severity of Dependence Scale (SDS) is a www.emcdda.europa.eu/html.cfm/index7343eN.html Dependence Scale 5-item questionnaire that provides a score (SDS) indicating the severity of dependence on opioids. Each of the five items is scored on a 4-point scale (0-3). Takes less than one minute to complete.
See appendix for screening tools
4.3 Guidance of levels of drinking Gavin DR; Ross HE; Skinner HA. (1989) ‘Diagnostic validity of the Drug Abuse Screening Test in the assessment of DSM-III drug disorders’, British Journal of Recommendations for drinking have been issued by various Addiction 84(3): 301-307 bodies including the Department of Health, Royal College of Ghodse H (2010). Ghodes’s Drugs and Addictive Behaviour; a guide to Physicians & NHS. treatment. 4thed ,Cambridge University Press. Chapter 6 Assessment; Appendix 4 Hamid Ghodse Substance Abuse Assessment Questionnaire 5.0 References and useful resources Appendix 7 & 8; Opiate Withdrawal; Appendix 9 Attendance Record Alcohol and Drug Abuse Institute Library, University of Washington; Substance Health and Social Care Information Centre ((2014 )Drug Misuse Use Screening & Assessment Instruments Database statistics,England 2014 http://lib.adai.washington.edu/instruments/ http://www.hscic.gov.uk/catalogue/PUB15943 ASH (2015) Smoking statistics Home Office (2015) Drug Misuse: Findings from the 2014/15 Crime Survey for http://www.ash.org.uk/files/documents/ASH_93.pdf England Boston Children’s Hospital Adolescent Substance Abuse Program – research and Wales and resources for SBIRT with adolescents and children. https://www.gov.uk/government/uploads/system/uploads/attachment_data/ http://www.teensubstancescreening.org/research/ file/462885/drug-misuse-1415.pdf Crome I and Ghodse A.H (2007) Drug Misuse on medical patients, in ICD 10 The International Classification of Diseases (ICD Handbook of Liaison Psychiatry, eds. Geoffrey Lloyd and Elspeth Guthrie, http://www.who.int/classifications/icd/en/ Cambridge University Press Darke, S., Ward, J., Hall, W., Heather, N. & Wodak, A. (1991). The Opiate Treatment Public Health England (2016) Health matters: harmful drinking and alcohol Index (OTI) Researcher's Manual. National Drug and Alcohol Research Centre dependence https://www.gov.uk/government/publications/health-matters- Technical Report Number 11. Sydney: National Drug and Alcohol Research harmful-drinking-and-alcohol-dependence/health-matters-harmful-drinking- Centre and-alcohol-dependence Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, Royal College of General Practitioners (2013): Certificate in the management abbreviated as DSM-V of drug abuse: a free e-learning course, which takes three hours to complete http://www.dsm5.org/Pages/Default.aspx aimed at all healthcare professionals. The free drugs eLearning module covers: http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%2 • evidence-based management of substance misuse 0Sheet.pdf • risks associated with poly drug use European Monitoring Centre Drugs and Drug Addiction: The Evaluation • screening and assessment in primary care Instruments Bank (EIB) online archive of freely available instruments for • prescribing treatments opioid users evaluating drug-related interventions. http://www.emcdda.europa.eu/eib • social context Foxcroft D, R. et al (2015) Accuracy of Alcohol Use Disorders Identification Test • older drug users. for Detecting Problem Drinking in 18–35 Year-Olds in England: Method Skinner, H.A (1982) Drug Abuse Screening Test (DAST), Addiction Research Comparison Study Alcohol& Alcoholism. 50: 244-250 Foundation. http://alcalc.oxfordjournals.org/content/50/2/244.abstract?etoc
8 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
Appendix: Screening tools used in 1.0 The AUDIT (Alcohol Use Disorders Identification Test) substance use Screening Tools There are a range of tools available for the screening of drug and alcohol use. These tools address l Pattern of substance use i.e. quantity, frequency and duration l Assessment of mental, physical and social problems associated with substance use l Assessment of extent of use, misuse, harmful use and dependence, as well as degree of dependence AUDIT is a screening instrument of good sensitivity and specificity for detecting hazardous and harmful drinking among people not seeking treatment for alcohol problems. The full AUDIT comprises 10 questions.
Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence
2.0 AUDIT – C is a shortened version Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive.
9 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
3.0 FAST 4.0 The Drug Abuse Screening Test (DAST) FAST is a rapid and efficient screening The Drug Abuse Screening Test (DAST) was developed in 1982 and is still an excellent tool for detecting alcohol misuse in the screening tool. It is a 28-item self-report scale that consists of items that parallel those A&E setting. of the Michigan Alcoholism Screening Test (MAST). The DAST has “exhibited valid The FAST Alcohol Screening Test is a 4- psychometric properties” and has been found to be “a sensitive screening instrument item initial screening test taken from for the abuse of drugs other than alcohol. AUDIT. It was developed for busy clinical Instruction for use: The following questions concern information about your settings as a two-stage initial screening involvement with drugs. Drug abuse refers to (1) the use of prescribed or “over-the- test that is quick to administer since counter” drugs in excess of the directions, and (2) any non-medical use of drugs. >50% of patients are identified by using Consider the past year (12 months) and carefully read each statement. Then decide just the first question. This version also whether your answer is YES or NO and check the appropriate space. Please be sure to provides the remaining questions from answer every question. AUDIT to be administered to those who are FAST positive in order to obtain a full 1. Have you used drugs other than those required for medical reasons? yes No AUDIT score. 2. Have you abused prescription drugs? yes No The Fast Alcohol Screening Test (FAST) is a simpler test that you can use to check 3. Do you abuse more than one drug at a time? yes No whether your drinking has reached 4. Can you get through the week without using drugs hazardous levels. FAST consists of four (other than those required for medical reasons)? yes No questions, listed below. The number after 5. are you always able to stop using drugs when you want to? yes No each answer is that answer's score. 6. Do you abuse drugs on a continuous basis? yes No 1. How often do you drink eight or more 7. Do you try to limit your drug use to certain situations? yes no units (men) or six or more units (women) on 8. Have you had “blackouts” or “flashbacks” as a result of drug use? yes No one occasion? 9. Do you ever feel bad about your drug abuse? yes No l never (if this is your answer you 10. Does your spouse (or parents) ever complain about your involvement with drugs? yes No can stop the test) 11. Do your friends or relatives know or suspect you abuse drugs? yes No l less than monthly (1) l monthly (2) 12. Has drug abuse ever created problems between you and your spouse? yes No l weekly (3) 13. Has any family member ever sought help for problems related to your drug use? yes No l daily or almost daily (4) 14. Have you ever lost friends because of your use of drugs? yes No 2. How often during the last year have you 15. Have you ever neglected your family or missed work because of your use of drugs? yes No been unable to remember what happened the night before because you had been 16. Have you ever been in trouble at work because of drug abuse? yes No drinking? 17. Have you ever lost a job because of drug abuse? yes No l never (0) 18. Have you gotten into fights when under the influence of drugs? yes No l less than monthly (1) 19. Have you ever been arrested because of unusual behaviour while l monthly (2) under the influence of drugs? yes No l weekly (3) 20. Have you ever been arrested for driving while under the influence of drugs? yes No l daily or almost daily (4) 21. Have you engaged in illegal activities in order to obtain drug? yes No 3. How often during the past year have you failed to do what was normally expected of 22. Have you ever been arrested for possession of illegal drugs? yes No you because you had been drinking? 23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake? yes No l never (0) 24. Have you had medical problems as a result of your drug use l less than monthly (1) (e.g., memory loss, hepatitis, convulsions, bleeding, etc.) yes No l monthly (2) 25. Have you ever gone to anyone for help for a drug problem yes No l weekly (3) l daily or almost daily (4) 26. Have you ever been in a hospital for medical problems related to your drug use? yes No 4. In the last year has a relative or friend, or 27. Have you ever been involved in a treatment program specifically related to drug use? yes No a doctor or other health worker been 28. Have you been treated as an outpatient for problems related to drug abuse yes No concerned about your drinking or suggested that you cut down? Scoring and interpretation: A score of “1” is given for each YES response, except for items 4, 5, and 7, for which a NO response is given a score of “1.” Based on data from a heterogeneous psychiatric patient l no (0) population, cut off scores of 6 through 11 are considered to be optimal for screening for substance use l yes, on one occasion (1) disorders. Using a cut off score of 6 has been found to provide excellent sensitivity for identifying patients l yes, on more than one occasion (2) with substance use disorders as well as satisfactory specificity (i.e., identification of patients who do not have substance use disorders). Using a cut off score of <11 somewhat reduces the sensitivity for identifying patients with substance use disorders, but more accurately identifies the patients who do not have a A FAST score of three or more substance use disorders. Over 12 is definitely a substance abuse problem. In a heterogeneous psychiatric indicates that you're drinking at a patient population, most items have been shown to correlate at least moderately well with the total scale hazardous level. scores. The items that correlate poorly with the total scale scores appear to be items 4,7,16,20, and 22. 10 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
5.0 DAST 10 Interpretation of Score This is a summarised version of the full 28 item screening tool Score Degree of Problems Suggested Action “Drug abuse” refers to (1) the use of prescribed or over the Related to Drug Abuse counter drugs in excess of the directions, and (2) any nonmendical use of drugs. 0 No problems reported None at this time The various classes of drugs may include cannabis (marijuana, 1‐2 Low level Monitor, re ‐assess at a hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium later date diazepam), barbiturates, cocaine, stimulants (e.g., speed), 3‐5 Moderate level Further investigation hallucionogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages. 6‐8 Substantial level Intensive assessment 9‐10 Severe level Intensive assessment
(Source: Addiction Research Foundation (1982)
6.0 PADDINGTON ALCOHOL TEST 2011 PADDINGTON ALCOHOL TEST 2011 PATIENT IDENTIFICATION STICKER: NAME ‘make the connection’ D.O.B.
A. PAT for TOP 10 presentations – circle as necessary B. Clinical Signs of alcohol use C. Blood Alcohol Concentration (refer direct from resusc. room if BAC>80mgs/100ml) BAC =…………..mgs/100ml 1. FALL (incl. trip) 2. COLLAPSE (incl. fits) 3. HEAD INJURY 4. ASSAULT 5. ACCIDENT 6. UNWELL 7. GASTRO - INTESTINAL 8. CARDIAC (i. Chest pain) 9. PSYCHIATRIC (incl. DSH & OD) please state 10. REPEAT ATTENDER Other (please state)
Only proceed after dealing with patient’s ‘agenda,’ i.e. patient’s reason for attendance.
“We routinely ask all patients having …(above presentation)…about their alcohol use.”
1 How often do you drink alcohol ? Never PAT ends Less than weekly ____ times per week Advise against daily drinking. Every day May be dependent. Consider thiamine (? Nutrition) & chlordiazepoxide (? CIWA). (continue to next question) What is the most you will drink in any one day? (UK alcohol units) 2 If more than twice daily limits (8 units/day for men, 6 units/day for women) PAT +ve
Use the following guide to estimate total daily units. (Standard pub units in brackets; home measures often three times the amount!)
Beer /lager/cider Pints (2) Cans (1.5) Litre bottles (4.5)
Strong beer /lager /cider Pints (5) Cans (4) Litre bottles (10)
Wine Glasses (1.5) 750ml bottles (9) Alcopops
Fortified Wine (Sherry, Port, Martini) Glasses (1) 750ml bottles (12) 330ml bottles (1.5)
Spirits (Gin, Vodka, Whisky etc) Singles (1) 750ml bottles (30) (continue to Q3 for all)
YES (PAT+ve) 3 Do you feel your attendance at A&E is related to alcohol? NO
If PAT +ve give feedback e.g. “Can we advise that your drinking is harming your health”. “It is recommended that you do not regularly drink more than 4 units/day for men or 3 units/day for women”. We would like to offer you further advice. Would you be willing to see our YES alcohol health worker? (Remember direct referral if BAC>80mgs/100ml) NO If “YES” to Q5 give ANS appointment card and leaflet and make appointment in diary @ 9am to 10am. Other appointment times available, please speak to ANS or ask patient to contact (phone number on app. card). Give alcohol advice leaflet (“Units and You”) to all PAT+ve patients, especially if they decline AHW appointment.
Please note here if patient admitted to ward ………………………………………………………. Referrer’s Signature Name Stamp Date:
ANS OUTCOME:
11 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
A. History B. Clinical Signs C. Blood Alcohol Concentration
A. History PAT(2009) is a clinical and therapeutic tool to ‘make the connection’ between ED attendance and drinking. Any ED doctor or nurse can follow PAT to give Brief Advice (BA) taking less than two minutes for most patients. BA is followed by the offer of a Brief Intervention (BI) from the Alcohol Nurse Specialist (ANS). BI is a specialist session lasting more than 20 minutes. This reduces the likelihood of re-attendance at the ED
PAT Gain the patient’s confidence: Deal with the patient’s reason for attending first, so they are in a receptive frame of mind for receiving Brief Advice. Then apply PAT for ‘THE TOP 10’ presentations or when signs of alcohol use. PAT takes less than a minute for most patients who drink. ROUTINE Q1 ‘We routinely ask all patients having (this presentation) if they drink alcohol - do you drink?’ If No: PAT-ve, discontinue (providing clinician agrees with the answer). QUANTITY Q2: “What is the most you will drink in any one day?” 1 Unit (UK) = 10ml alcohol = 8gms alcohol Units = % ABV x volume (in litres) % ABV is ‘% of alcohol by volume’ as indicated on bottle or can. FREQUENCY Q3: “How often do you drink?” Daily drinking may indicate dependence. Any heavy drinking risks adverse consequences and A&E re-attendance. NB Hazardous drinkers should be given leaflet “Units & You”. MAKE THE Everyone who says yes to Q1 should be asked Q4: CONNECTION “Do you feel your current attendance at A&E is related to alcohol?” If yes, then you have successfully started Brief Advice (BA) by the patient associating their drinking with resulting hospital attendance.
B. Clinical Signs of acute alcohol use: ‘SAFE Moves: ABCD’ ‘S’mell of alcohol. ‘S’peech: varying volume & pace; slurring & jumbled. ‘A’ffect: variable judgement & inappropriate behaviour; euphoria/depression; decreased co-operation; emotional. ‘F’ace: sweating/flushed (cushingoid – chronic), ? injury. ‘E’yes: red conjunctiva, nystagmus*, ophthalmoplegia* ‘Moves’: fine motor control*, incoordination (acute cerebellar syndrome)*. gross motor control (walking)*, (truncal ataxia – chronic)*. Airway: snoring with obstruction. Inhalation of vomit - ? Mallory-Weiss Breathing: slow/shallow, hypoxia with CO2 retention - ? air entry Circulation: tachycardia, irregularity. Hypotension; vasodilatation with heat loss. Collapse. Urinary retention or incontinence; but ? dehydration. Disability: variable alertness*, confusion*, hallucinations*, sleepiness. ? GCS.
* Signs of possible Wernicke’s - give thiamine iv. In UK: ‘Pabrinex’, BNF ‘54’, 2007 onwards. For monitoring withdrawal use ‘CIWA’ (Clinical Institute Withdrawal Assessment)
C. Resusc. Room: request Blood Alcohol Concentration, BAC - same grey bottle as for glucose - for all 5 presentations of:- 1. Collapse 2. Self-harm 3. Trauma 4. Gastro-intestinal/Abdominal 5. Chest pain If BAC + i.e. >10mgs/100ml: apply PAT when out of Resusc. Or direct referral to ANS’s if >80mgs Ref. Touquet R & Brown A. PAT(2009) – Revisions to the PAT. Alcohol & Alcoholism 2009;44(3):284-6. For further information about the Paddington Alcohol Test (PAT), ‘SAFE Moves’ or BAC contact: Prof. Robin Touquet FCEM - [email protected] or Adrian Brown RMN – [email protected] or Win Keane RMN – [email protected]
12 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
7.0 FIVE-SHOT QUESTIONNAIRE 3. Have people annoyed you by criticising your drinking? 1. How often do you have a drink containing alcohol: (0.0) No (0.0) Never (1.0) Yes (0.5) Monthly of less 4. Have you ever felt bad or guilty about your drinking? (1.0) Two to four times a month (0.0) No (1.5) Two to three times a week (1.0) Yes (2.0) Four or more times a week 5. Have you ever had a drink first thing in the morning to 2. How many drinks containing alcohol do you have on a steady your nerves or get rid of a hang-over? typical day when you are drinking? (0.0) No (0.0) 1 or 2 (1.0) Yes (0.5) 3 or 4 (1.0) 5 or 6 Scoring Score of 2.5 or greater indicates possible alcohol misuse (1.5) 7 to 9 and the need for further investigation (2.0) 10 or more Maximum Score = 7. (Seppa et al, 1`8). the past 12 months… Circle 1. Have you used drugs other than those required for medical reasons? Yes No 2. Do you abuse more than one drug at a time? Yes No 3. Are you unable to stop abusing drugs when you want to? Yes No 4. Have you ever had blackouts or flashbacks as a result of drug use? Yes No 5. Do you ever feel bad or guilty about your drug use? Yes No 6. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No 7. Have you neglected your family because of your use of drugs? Yes No 8. Have you engaged in illegal activities in order to obtain drugs? Yes No 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? Yes No 10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? Yes No Scoring: Score 1 point for each question answered “Yes,” except for question 3 for which a “No” Score: receives 1 point.
8.0 MAST THE MICHIGAN ALCOHOL SCREENING TEST 2. Have you ever awakened the morning after some (MAST) The original MAST was a 25-item questionnaire. drinking the night before and found that you could not remember a part of the evening? Later, the MAST was downsized to a 22-item YES or NO questionnaire that not unlike the original instrument, 3. Does any near relative or close friend ever worry or was designed to provide a quick and accurate screening complain about your drinking? tool for identifying alcohol-related problems and YES or NO alcoholism. 4. Can you stop drinking without difficulty after one or The MAST has been productively used in a number of diverse two drinks? settings with various populations. YES or NO The following represents the 22 questions that make up the 5. Do you ever feel guilty about your drinking? MAST. YES or NO Please answer YES or NO to the following questions: 6. Have you ever attended a meeting of 1. Do you feel you are a normal drinker? (“normal” - drink as Alcoholics Anonymous (AA)? much or less than most other people) YES or NO YES or NO 7. Have you ever gotten into physical fights when drinking? YES or NO
13 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
8. Has drinking ever created problems between you and a Scoring near relative or close friend? Please score one point if you answered the following: YES or NO 1. No 9. Has any family member or close friend gone to anyone for 2. Yes help about your drinking? 3. Yes YES or NO 4. No 10. Have you ever lost friends because of your drinking? 5. Yes YES or NO 6. Yes 11. Have you ever gotten into trouble at work because 7 through 22 : Yes of drinking? Add up the scores and compare to the following score card: YES or NO 12. Have you ever lost a job because of drinking? 0 - 2 No apparent problem YES or NO 3 - 5 Early or middle problem drinker 13. Have you ever neglected your obligations, your family, 6 or more Problem drinker or your work for two or more days in a row because you Source: MAST Alcohol Test were drinking? Short Michigan Alcoholism Screening Test – YES or NO Geriatric Version 14. Do you drink before noon fairly often? (S-MAST- G) © The Regents of the University of YES or NO Michigan, 1991. 15. Have you ever been told you have liver trouble such YES (1) NO (0) as cirrhosis? 1. When talking with others, do you ever underestimate how YES or NO much you actually drink? 16. After heavy drinking have you ever had delirium tremens 2. After a few drinks, have you sometimes not eaten or been (D.T.'s), severe shaking, visual or auditory (hearing) able to skip a meal because you didn't feel hungry? hallucinations? 3. Does having a few drinks help decrease your shakiness or YES or NO tremors? 17. Have you ever gone to anyone for help about 4. Does alcohol sometimes make it hard for you to remember your drinking? parts of the day or night? YES or NO 5. Do you usually take a drink to relax or calm your nerves? 18. Have you ever been hospitalized because of drinking? 6. Do you drink to take your mind off your problems? YES or NO 7. Have you ever increased your drinking after experiencing 19. Has your drinking ever resulted in your being hospitalized a loss in your life? in a psychiatric ward? 8. Has a doctor or nurse ever said they were worried or YES or NO concerned about your drinking? 20. Have you ever gone to any doctor, social worker, 9. Have you ever made rules to manage your drinking? clergyman or mental health clinic for help with any emotional problem in which drinking was part of the 10. When you feel lonely, does having a drink help? problem? TOTAL S-MAST-G SCORE (0-10) _____ YES or NO Scoring: 2 or more “yes” responses indicative of alcohol 21. Have you been arrested more than once for driving under the influence of alcohol? problem. YES or NO 22. Have you ever been arrested, even for a few hours because of other behavior while drinking? (If Yes, how many times ______) YES or NO
14 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
9.0 CRAFFT C - Have you ever ridden in a CAR driven by someone Screening using the CRAFFT begins by asking the adolescent to (including yourself) who was “high” or had been using “Please answer these next questions honestly”; telling him/her alcohol or drugs? “Your answers will be kept confidential”; and then asking three R - Do you ever use alcohol or drugs to RELAX, feel better opening questions. about yourself, or fit in? If the adolescent answers “No” to all three opening questions, A - Do you ever use alcohol/drugs while you are by yourself, the provider only needs to ask the adolescent the first question ALONE? - the CAR question. If the adolescent answers “Yes” to any one or F - Do you ever FORGET things you did while using alcohol more of the three opening questions, the provider asks all six or drugs? CRAFFT questions. F - Do your family or FRIENDS ever tell you that you should CRAFFT is a mnemonic acronym of first letters of key words in cut down on your drinking or drug use? the six screening questions. The questions should be asked - Have you gotten into TROUBLE while you were using exactly as written. T alcohol or drugs?
10.0 CAGE ASSESSMENT (Brief version) The CAGE or CAGE-AID should be preceded by these two C Have you ever tried to Cut back on your use? questions: A Have you ever been Annoyed/ Angered when questioned 1. Do you drink alcohol? about your use? 2. Have you ever experimented with drugs? G Have you ever felt Guilt about your use? If the patient has experimented with drugs, ask the CAGE-AID E Have you ever had an Eye-opener to get started in the questions. If the patient only drinks alcohol, then ask the CAGE morning? questions. The Cage Assessment is a quick questionnaire to help CAGE-AID Questions determine if an alcohol assessment is needed. If you answer 1. In the last three months, have you felt you should cut down yes to two or more of these questions, then an assessment is or stop drinking or using drugs? advised. Yes CAGE-AID Questionnaire No CAGE-AID (Adapted to Include Drugs) is a version of the CAGE alcohol screening questionnaire, adapted to include drug use. 2. In the last three months, has anyone annoyed you or gotten This four item screening tool takes approximately 1 minute to on your nerves by telling you to cut down or stop drinking administer and score. The target population for the CAGE-AID is or using drugs? both adults and adolescents and can be administered by patient Yes interview or self-report in a primary care setting. No Evidence 3. In the last three months, have you felt guilty or bad about l Easy to administer, with good sensitivity and specificity how much you drink or use drugs? (Leonardson, et al, 2005). Yes l More sensitive than original CAGE questionnaire for No diagnosis of substance use disorder (Brown & Rounds, 1995) 4. In the last three months, have you been waking up wanting l Less biased in term of education, income, and sex then the to have an alcoholic drink or use drugs? original CAGE questionnaire(Brown & Rounds, 1995). Indications Yes No l Intended as a brief clinical screening during primary care visits Reprinted with permission from Dr. R.L. Brown. Advantages Scoring l The CAGE-AID is well suited for use in a primary Of the 4 items, a "yes" answer to one item indicates a possible care facility.+ substance use disorder and a need for further testing. l Quick and easy to administer Reference l Easily incorporated into a medical history protocol or Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and intake procedure detection of substance use disorder among inpatients ages 18 to 49: an opportunity for prevention. Preventive Medicine. 1998;27:101-110. Limitations l Screening for alcohol and drug usage conjointly rather than separately
15 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
11 .0 Karl Fagerstrom Nicotine Tolerance Questionnaire a) Yes For each statement, circle the most appropriate number that 1 best describes you. b) No Total Point(s): ______0 Point(s) 4. Do you smoke more during the first hours after waking than during the rest of the day? 1. How many cigarettes do you smoke per day? a) Yes a) 10 or less 1 b) 11 – 20 b) No 0 0 1 5. Which cigarette would you be the most unwilling to c) 21 – 30 give up? 2 a) First in the morning d) 31 or more 1 3 b) Any of the others 2. How soon after you wake up do you smoke your 0 first cigarette? 6. Do you smoke even when you are very ill? a) 0 – 5 min a) Yes b) 30 min 1 c) 31 – 60 min b) No 3 0 2 1 TOTAL SCORE d) After 60 min 0 LEVEL OF DEPENDENCE 3. Do you find it difficult to refrain from smoking in places 0 – 3 points Low where smoking is not allowed (e.g. hospitals, government offices, cinemas, libraries etc)? 4 – 6 points Medium 7 – 10 points High
12.0 Opiate Treatment Index (OTI) A score of 31 or higher indicates ‘severe alcohol dependence’. The OTI consists of six independent outcome domains. The A score of 16 -30 indicates ‘moderate dependence’ domains chosen to reflect the dimensions of treatment outcome were: Drug Use, HIV Risk-taking Behaviour, Social A score of below 16 usually indicates only a mild physical Functioning, Criminality, Health Status, and Psychological dependence. Adjustment. A chlordiazepoxide detoxification regime is usually indicated for http://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resourc someone who scores 16 or over. es/TR.011.pdf Source: Darke, S et al (1991). 14.0 The Severity of Dependence Scale (SDS) 13.0 SADQ (Severity of Alcohol Dependence Questionnaire) The Severity of Dependence Scale (SDS) is a 5-item questionnaire that provides a score indicating the severity of The SADQ questions cover the following aspects of dependence dependence on opioids. Each of the five items is scored on a syndrome: 4-point scale (0-3). It takes less than one minute to complete. l physical withdrawal symptoms 15.0 Assessment of levels of drinking l affective withdrawal symptoms Recommended levels of drinking: l relief drinking l frequency of alcohol consumption Department of Health The Royal College of l speed of onset of withdrawal symptoms. Physicians (RCP) Scoring: Men should not regularly no more than 21 units Answers to each questions are rated on a four point scale: drink more than per week Almost never = 0 3-4 units of alcohol a day Sometimes = 1 Women women should not no more than 14 units Often = 2 regularly drink more per week Nearly always = 3 than 2-3 units a day 16 SUBSTANCE MISUSE FACT SHEETS Category III – ASSESSMENT AND SCREENING TOOLS
Note: 'Regularly' means drinking every day or most days of the of liver disease for those who drink daily or near daily compared week. If you do drink more heavily than this on any day, allow 48 with those who drink periodically or intermittently." alcohol-free hours afterwards to let your body recover. The House of Commons Science and Technology Committee RCP also state that it is recommended to have 2-3 alcohol-free advise that people should have at least two alcohol-free days a days a week to allow the liver time to recover after drinking week. anything but the smallest amount of alcohol. It is useful to assess the level of drinking based on unit of alcohol A quote from the RCP "in addition to quantity, safe alcohol limits to enable advice about reducing harmful effects of alcohol. must also take into account frequency. There is an increased risk
NHS – your drinking and you Men Women NHS – Your drinking and you no more than 3–4 units a day on a no more than 2–3 units a day on a Drinking within the lower-risk guidelines regular basis regular basis Drinking above the lower-risk more than 3–4 units a day on a more than 2–3 units a day on a guidelines, putting your health at regular basis regular* basis increasing risk Drinking in a way that puts your health more than 50 units per week (or more more than 35 units per week (or more at even higher risk than 8 units per day) on a regular basis than 6 units per day) on a regular basis
Drinking above the lower-risk guidelines Drinking above the higher-risk guidelines For men, drinking more than 3–4 units a day on a regular basis For men, drinking on a regular basis more than 8 units a day or puts your health at increasing risk. more than 50 units a week puts your health at higher risk. For women, drinking more than 2–3 units a day on a regular For women, drinking on a regular basis more than 6 units a day basis puts your health at increasing risk. or more than 35 units a week puts your health at higher risk.
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