Transcript Conducting an Outpatient Assessment for Substance

The Outpatient
Assessment
Quinn T. Chipley, M.A., M.D.
CAPTASA
January 30-31, 2015
DISCLAIMER
 This
presenter has no funding from any
institution, corporation, or agency
regarding the content of this presentation.
 Although
he loves his work at the
University of Louisville as the Counseling
Coordinator for the Health Sciences
Center students, that institution should in
no way be held responsible for the
content of this presentation.
Old Rules and New Rules:
Diagnostic Targets
“The Times,
They Are a Changin.’”
DSM-IV-TR Criteria for Alcohol
Dependence (Pertinent till October 2015)
Alcohol Dependence - Diagnostic Code 303.90 A maladaptive pattern of alcohol use, leading
to clinically significant impairment or distress, as manifested by three (or more) of the following,
occurring at any time in the same 12-month period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of alcohol
to
achieve Intoxication or desired effect
(b) markedly diminished effect with continued use of the same
amount of alcohol
(2) Withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for alcohol (refer to
Criteria A and B of the criteria sets for withdrawal from alcohol.)
(b) alcohol (or a closely related drug such as valium) is used to relieve
or avoid withdrawal symptoms
(3) alcohol is often used in larger amounts or over a longer period than was
intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control alcohol
use
(5) a great deal of time is spent in activities necessary to obtain alcohol, use
alcohol, or recover from its effects
(6) important social, occupational, or recreational activities are given up or
reduced because of alcohol use
(7) 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 (e.g. continued drinking despite recognition that an ulcer
was made worse by alcohol consumption)
DSM-IV-TR Criteria for Alcohol
Abuse (Pertinent till October 2015)
Alcohol Abuse - Diagnostic Code 305.00
A. A maladaptive pattern of alcohol use leading to clinically significant
impairment or distress, as manifested by one (or more) of the following,
occurring within a 12-month period:
(1) recurrent alcohol use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or
poor work performance related to alcohol use; alcohol-related
absences, suspensions, or expulsions from school; neglect of
children or household)
(2) recurrent alcohol use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a machine
when impaired by alcohol use)
(3) recurrent alcohol-related legal problems (e.g., arrests for
alcohol-related disorderly conduct)
(4) continued alcohol use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the alcohol (e.g., arguments with spouse about
consequences of Intoxication, physical fights)
B. The symptoms have never met the criteria for Alcohol Dependence.
DSM-IV-TR Criteria for Alcohol
Dependence (Pertinent till October 2015)- CONT.
Specifiers:
• With Physiological Dependence: evidence of tolerance
or withdrawal (i.e., either Item 1 or 2 is present)
• Without Physiological Dependence: no evidence of
tolerance or withdrawal (i.e., neither Item 1 nor 2 is
present)
Course specifiers
• Early Full Remission
• Early Partial Remission
• Sustained Full Remission
• Sustained Partial Remission
• On Agonist Therapy
• In a Controlled Environment
Side-Bar Note…….
What happened to blackouts? I cannot find
them mentioned directly, and it is a stretch to
include transient neurological impairment under
psychological sequleae.
BUT I ALWAYS ASK: “Have you had drinking
episodes in which other people report that you
continued speaking, ambulating or engaging in
other apparently conscious behaviors but you
retained no memory of those events?
DSM V Criteria for Substance Use
Disorders(Pertinent after October 2015)
“Criteria and Terminology
DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV.
Rather, criteria are provided for substance use disorder, accompanied by criteria for
intoxication, withdrawal, substance/medication-induced disorders, and unspecified substanceinduced disorders, where relevant. The DSM-5 substance use disorder criteria are nearly identical
to the DSM-IV substance abuse and dependence criteria combined into a single list, with two
exceptions. The DSM-IV recurrent legal problems criterion for substance abuse has been deleted
from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance, has been
added. In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or
more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV
substance abuse and three or more for DSM-IV substance dependence. Cannabis withdrawal is
new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets and
Axes Provided for Further Study”). Of note, the criteria for DSM-5 tobacco use disorder are the
same as those for other substance use disorders. By contrast, DSM-IV did not have a category for
tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in
DSM-5. Severity of the DSM-5 substance use disorders is based on the number of criteria
endorsed: 2–3 criteria indicate a mild disorder; 4–5 criteria, a moderate disorder; and 6 or more,
a severe disorder. The DSM- IV specifier for a physiological subtype has been eliminated in DSM5, as has the DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5
substance use disorder is defined as at least 3 but less than 12 months without substance use
disorder criteria (except craving), and sustained remission is defined as at least 12 months
without criteria (except craving). Additional new DSM-5 specifiers include “in a controlled
environment” and “on maintenance therapy” as the situation warrants.”
Source: http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
Two Occasions for the
Outpatient Interview
 The
General Intake Interview for all
persons who present for medical or
counseling services
“All Comers”
 The
Substance-focused interview when
the referral indicates
“For Cause”
Three Possible Locations
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The “general practice” setting
e.g. – psychology, LCSW, counseling
practice, psychiatry, Family medicine,
Internal Medicine, Pediatric, EAP
A specific out-patient Substance Assessment
and Treatment practice
A Professionals’ Health organization (e.g. –
physicians, dentists, nurses, pharmacists, et al.)
The only real difference
between “All Comers” and
“For Cause,” and among the
three locations, is the
reduction of False Negatives
and the increase in True
Positives as “index of suspicion
increases.
This means that the good outpatient clinical
interview will always include questions
about alcohol and other substances
Increased Suspicion Usually
means Increased Assessment
Time
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In an “All Comers” clinical interview of 50 minutes, I
get to spend about fine minutes initially on substance
issues.
In a “For Cause” clinical Interview of 50 minutes, I get
to spend as much as 25 minutes on substance issues
The agency to which I most frequently refer students
for who I detect substance problems will usually
expect 2 hours and 15 minutes of time
The Professionals Health Program interviews can
involve several hours or more and also include a
request for an observed urine laboratory panel.
The General Intake Interview
for “All Comers”
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Always ask the client about Substance use
directly regardless of “presenting problem” or
“chief complaint.”
Use “Presumptive Interview” techniques
e.g. – rather than asking “Do you drink
alcohol?” start with the question “When
was the last time you had an
alcohol beverage?” (If the client is a non
drinker, he or she will tell you immediately)
Be Presumptive about All
Substances, not Just Alcohol
Ask, “What other recreational drugs do you
use?”
I also probe a bit even if none are offered.
“Have you ever tried any anything, such as
weed for example?”
The General Intake Interview
for “All Comers” – Cont.
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Ask for quantifiable answers:
Ask for Frequency. (I scramble the possibilities: “Once a week? Once
a month? Three times a week? Every day?”)
Ask for Quantities: “Assuming a drink is one ounce of 80 proof or I glass
of wine or one 12 oz. beer, how many drinks do you have an
occasion?
Ask for Excesses: “How many time in the past year have you had more
than: [a) for a man, 4 drinks b) for a woman, 3 drinks] in a four hour
period?” and “How many times in the past year would you guess that
you would have exceeded a .08 blood alcohol level if you had been
tested?
Ask for family history of substance
“Who in your family tree – up, down, or sideways along the branches –
has or had a problem with alcohol or other drugs?”
Use of Assessment Instruments
C- Cut Back A – Angry G= Guilty E= Eye Opener
Never sell-short the C-A-G-E. It may have limits
(false negatives in particular) among women
(especially pregnant women) and college-age
drinkers, but results of 2/4 are a good indicator
for further assessment; 3/4 is always a call to
distinguish abuse from dependence (while that
opportunity still lasts), and 4/4 can very well
indicate a need for medical detox.
For college age populations, there is some utility
in substituting “Auto” for “Angry” and asking if
the client thinks he or she has ever driven while
drunk (even if never arrested fro the event).
Instruments – Cont.
The AUDIT (Alcohol Use Disorders Indication Test)
Ten items long, forced-choice. Each scored 0 – 4.
Includes aspects of CAGE and aspects of the
quantifying questions. If you work in an environment
that allows clients time to fill out forms in advance of
an interview, consider it.
You still have to ask about other substances
See
http://www.agencymeddirectors.wa.gov/Files/aas.p
df
Saunders JB, Aasland OG, Babor TF et al.. Development of the Alcohol
Use Disorders Identification Test (AUDIT): WHO collaborative project on
early detection of persons with harmful alcohol consumption--II.
Addiction.1993. 88: 791– 803
Instruments- Cont.
SASSI-3 (Substance Abuse Subtle Screening
Inventory-3)
Paper or on-scree; 93 items for adults and 100
items for adolescents. Most useful, perhaps, as
a way to document defensiveness.
A good interviewer probably already knows the
defensiveness is therein the client, but if a
practice requires some more objective
documentation, this can help.)
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Instruments- Cont.
 The
MAC (McAndrew Alcoholism Scale)of
the MMPI-2.
 49 items out of the total 562 items. It hits
“covert” content because the items do
not directly mention drinking. If you have
the luxury of an MMPI-2, it is worth looking
at the MAC.
For more information see:
http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/41_MAC.pdf
Cups, Needles and Clippers
If you have the power, use it for good and not
evil!
There is SIGNIFICANT gain if you work in a setting
that can mandate an unannounced lab screen
(urine, plasma, or hair/ nails).
Even before the results come back in, the client
will often come back in to your office with a
statement like, “Oh, I just remembered…I think
maybe I DID take a hit off of….” or “You know,
now that I think about it, I maybe had 6 or 7
beers yesterday an not just 1 or 2.”
Placement? Not My Problem…
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Actually it is, but I am shamelessly shifting
responsibility to the 96-hour residential assessment
guys.
And it is a problem if I know immediately that a client
in front of me, whether “All Comer” or a “For Cause”
needs medical detox as a way to prevent a seizure
event; or even as means for compassionate
reduction of suffering. I have to act to get those
persons help immediately, and to inform them well of
possible dangers if they refuse to take the bestpractices suggestions.
That said, the legal-ethical assault on best-substance
dependence practices has complicated the picture.
Society is conspiring to make us watch folks fail lesser
treatments before they get what works. (For me, this
is a second-half of a first-step problem…)