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exhibit 2-2 Tools To Assess pain level (continued)
Bird, 2003; Brunton, 2004.
exhibit 2-3 Tools To Assess several Dimensions of pain
Department of Veterans Affairs & Department of Defense, 2003.
Assessing Substance Use and Addiction
As with assessing pain and function, assessing patient self-reports of substance use, whether via interviews or structured self-report
questionnaires, should be corroborated by other sources of information (e.g., medical records, interviews with family, urine toxicol- ogy, information from State prescription mon itoring programs) (Katz & Fanciullo, 2002).
exhibit 2-4 Tools To Assess pain Interference With life Activities and Functional capacities
When initiating a conversation about alcohol
and drug use, clinicians should:
• Approach the topic matter-of-factly, handling it as part of the overall medical history.
• Incorporate questions about drug and alcohol use into a general behavioral health inventory including discussion of other lifestyle behaviors (e.g., diet, exercise).
• Ask about nicotine and caffeine use; questions about use of these substances provide opportunities to move to assess ment of other substances, beginning with alcohol, the most commonly abused substance.
• Assure patients that honest answers to questions of substance use are necessary to developing a treatment plan and that their responses will remain confidential.
A good prescreening question is, “When did you last have a drink of beer, wine, or liquor?” If the patient reports drinking within the past year, the clinician should ask questions to determine:
• Frequency (“How many days per week do you typically drink alcohol?”)
• Quantity (“How much alcohol do you
drink on a typical drinking occasion?”)
• Evidence of binge drinking (for men: “On any day in the past year, have you ever had five or more drinks?”; for women: “On any day in the past year, have you ever had four or more drinks?”)
The clinician should ask the patient to define what the patient means by “a drink” (e.g.,
an 8-ounce glass, half a glass). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines one drink as one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof dis tilled spirits. According to NIAAA (2005), if the male patient drinks more than 4 standard drinks in a day (or more than 14 drinks per
week), or more than 3 drinks in a day (or more than 7 drinks per week) for the female patient, the person is at increased risk for developing alcohol-related problems.
Whether or not the patient reports drinking, the clinician should probe for the use of licit and illicit drugs, starting with the most com monly used illicit drug in the United States: marijuana. Questions can continue to address other major classes of drugs with abuse poten tial (e.g., depressants, stimulants, opioids),
with particular attention to use related to controlling pain or the patient’s anxiety and fear of pain (Passik & Kirsch, 2004). Exhibit
2-5 summarizes the substances that patients should be asked about using.
NIDA provides a Web-based tool that helps clinicians screen for tobacco, alcohol, and illicit and nonmedical prescription drug use, and suggests levels of intervention. The tool is at http://ww1.drugabuse.gov/nmassist.
screening for substance Use
Although the amount of substance used is significant, it is more important to evaluate the consequences of the drug and alcohol use on life domains, such as family, work or school, and involvement with the criminal justice system (e.g., arrests for driving under the influence). When drug or alcohol use interferes with normal function, addiction is
likely. Furthermore, addiction is characterized
by impaired ability to control use of the sub stance. Asking whether the patient has ever attempted to decrease the amount consumed is an approach to determining his or her abil
ity to modulate use. In the case of prescription medication, a patient’s loss of control may manifest as the inability to ration pills until
the next prescription, so the patient’s partner may oversee the dispensing of the medications.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000) provides criteria for determining substance dependence that enable the clinician to distinguish between patients with at-risk substance use and those whose
use is consistent with an SUD (Exhibit 2-6). It is important to remember that, essentially, all patients taking prescribed opioids or seda tives on a long-term basis will have a degree of tolerance and withdrawal and that these criteria are not indicative of addiction absent the “maladaptive pattern of substance use.”
exhibit 2-5 Items To Include in substance Use Assessment
exhibit 2-6 Dsm-Iv-Tr criteria for substance Abuse and substance
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.
Although a patient’s former drug of choice is the one that is most likely to lead to cravings and relapse (Daley, Marlatt, & Spotts, 2003; Gardner, 2000), clinical experience suggests that a person with a history of an SUD involv ing any drug is susceptible to developing a cross-addiction with opioids (Covington,
2008; Savage, 2002).
Clinicians should try to determine patients’ recovery status, which is crucial in developing a treatment plan (Exhibit 2-7). Many patients will be forthcoming about past or recent sub stance abuse during a comprehensive assess ment. Some patients who have an SUD lack
a full appreciation of the effects of substances,
prescribed or otherwise, on their function; however, family members can usually provide this information.
Several standardized tools for SUD screening are listed in Exhibit 2-8. Information on how to obtain the tools is in Appendix B. Most tools are short, can be self-administered, and can be integrated into the health-screening forms the patient completes prior to seeing the clinician. Although no tool is a substitute for a good clinical interview, screening is essential to case finding and a useful comple ment to the patient interview, the physical exam, and ongoing observation (Fishman,
exhibit 2-7 steps Following substance Abuse Assessment
Adapted from Passik & Kirsh, 2004.
exhibit 2-8 Tools To screen for substance Use Disorders
The Substance Abuse and Mental Health
Services Administration’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) initiative may be helpful in the primary care context (Exhibit 2-9). More information can be obtained from the Center for Substance Abuse Treatment (CSAT,
1999a). Research findings on SBIRT are available from National Association of State Alcohol and Drug Abuse Directors (2006).