Screening and Assessment
A brief overview of screening and assessment with links to key evidence and resources listing tools used to screen and assess for drug, alcohol and nicotine use.
This is the most important aspect of identifying substance use, misuse and dependence in patients, it includes the following:
- History taking to ask questions about all aspects of substance use and the impact this has on the individual
- Recording and making observations of the individual
- Using screening tools
- Undertaking biological testing for confirmation of substance use
When patients present to services, the reasons for presenting may be either directly or indirectly related to substance use. Screening and assessment are not the same: screening is an initial, simple enquiry about indicators of health problems the results of which may lead to further assessment. Often, screening takes place when the individual first presents to services, and can sometimes be referred to as triage.
The purpose of assessment is to determine the level of impact substance use is having on the individual’s health both physical and mental and also on their wider social network and functioning. Assessment is an in-depth, comprehensive, ongoing and sometimes protracted process, which includes the use of detailed history taking, instruments, and biological tests regularly so to formulate the case and monitor progress.
Definition and classification of dependent (addictive) and non-dependent use.
There are two diagnostic tools specific criteria for the diagnosis of substance problems and dependence.
- The International Classification of Diseases (ICD-11) https://icd.who.int/en and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-V) https://www.verywellmind.com/dsm-5-criteria-for-substance-use-disorders-21926
- ICD-11 defines ‘harmful use’ of a substance separately from ‘dependence’ on a substance, the DSM-V criteria link these two concepts together as a single disorder measured on a continuum from mild to severe.
The key principle underlying an assessment is to determine the nature and extent of substance use and the interaction of use and psychological and physical symptomatology.
Every patient should be assessed for substance use. It is important to emphasise that the style of questioning, i.e. that it should be non-judgmental, non-confrontational, and should be seen as part of engagement – the start – of the treatment process. It is important if feasible to build a relationship with the patient prior to administering assessment tools too rapidly.
Much depends on the context of the initial consultation or meeting. Avoidance of stereotyping is central to this process.
Reducing the stigma associated with addiction – the word itself now tagged with a degree of stigma – is a priority in drugs policy. Stigmatising attitudes contribute to drug harms and deaths through delaying access to treatment, leaving treatment early and increased risk-taking behaviour | Recovery Review blog, UK Wiping out stigma and from SDF Moving Beyond ‘People-First’ Language: A glossary of contested terms in substance use. This resource describes the issues around some language and key concepts that often cause contention and some that evolve from or perpetuate stigma and the prejudice it fosters.
In addition to taking a full assessment it is useful to obtain information from others (with permission) to assist in building up an accurate picture – this may include family members, friends, carers, other professionals e.g. GPs, social workers and in the case of young people school, college, tutors, teachers …
The assessment process
- Initial screening (presenting problem, current substance use, risk assessment including mental state and any safeguarding issues, confidentiality and consent)
- Comprehensive history (see Crome, I. and Ghodse, A. H. Drug Misuse in Medical Patients in Handbook of Liaison Psychiatry eds Lloyd, G. and Guthrie, E. Cambridge University Press. https://www.cambridge.org/core/books/handbook-of-liaison-psychiatry/drug-misuse-in-medical-patients/3DD85723EF7538C14D898F80CDA760D4 )
- Physical and mental state examination
- Biological testing
- Use of appropriate tools to monitor pattern of substance use, estimation of problems associated with substance use and assessment of dependence and degree of dependence
There are a wide range of tools available for the screening of drug and alcohol use details of which can be found in the resources listed below.
Evaluation Instruments Bank (EIB) from the EMCDDA is an online archive of freely available instruments for evaluating drug-related interventions. Details regarding copyright and/or possible use restrictions are specified for each instrument. https://www.emcdda.europa.eu/eib
Substance Use Screening & Assessment Instruments Database: this resource, produced by Library & Information staff at the Alcohol and Drug Abuse Institute, University of Washington, is intended to help clinicians and researchers find instruments used for screening and assessment of substance use and substance use disorders. http://lib.adai.washington.edu/instruments/
CASAA Assessment Library produced by the Center on Alcohol, Substance Use & Addiction, University of New Mexico, is a resource for substance abuse researchers and clinicians. http://casaa.unm.edu/inst.html
National Institute for Drug Abuse Screening and Assessment Tools Chart of evidence-based screening tools and assessment resource materials https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools
Result4 Addiction website https://www.result4addiction.net/ self-assessment of addiction, recovery, and mental health problems using the best scales currently available. Practitioners and researchers can dig deeper to find the evidence underpinning scales and their psychometric properties and compare a selection of scales measuring different aspects of addiction.
UNODC Basics of Addiction, Screening & Assessment, Treatment Planning & Care Coordination. (online training modules, password protected) https://www.unodc.org/unodc/en/treatment-and-care/volume-a-for-participants.html
Public Health England Collection Alcohol and drug misuse prevention and treatment guidance includes “Drug and alcohol screening and treatment tools” section https://www.gov.uk/government/collections/alcohol-and-drug-misuse-prevention-and-treatment-guidance#drug-and-alcohol-screening-and-treatment-tools
Public Health England Guidance Screening and brief advice for alcohol and tobacco use in inpatient settings https://www.gov.uk/government/publications/preventing-ill-health-commissioning-for-quality-and-innovation/guidance-and-information-on-the-preventing-ill-health-cquin-and-wider-cquin-scheme
National Centre for Education and Training on Addiction (NCETA), University of Flinders AOD Screening and Withdrawal Tools Collection https://aodscreening.flinders.edu.au/
Assanangkornchai, Sawitri (et al.)(2021) Clinical Screening for Illegal Drug Use, Prescription Drug Misuse and Tobacco Use pp 619-635 in Textbook of Addiction Treatment International Perspectives, eds. el-Guebaly, N., Carrà, G., Galanter, M., Baldacchino, A.M. Springer (https://www.springer.com/gb/book/9783030363901
Bobes-Bascarán, M. Teresa (et al.)(2021) Clinical Assessment of Alcohol Use Disorders pp 585-594 in Textbook of Addiction Treatment International Perspectives, eds. el-Guebaly, N., Carrà, G., Galanter, M., Baldacchino, A.M. Springer (https://www.springer.com/gb/book/9783030363901
Crome, I. and Ghodse, A. H. (2007) Chapter Drug Misuse in Medical Patients in Handbook of Liaison Psychiatry, Chapter 9 pp 180-220. eds Lloyd, G. and Guthrie, E. Cambridge University Press. https://www.cambridge.org/core/books/handbook-of-liaison-psychiatry/drug-misuse-in-medical-patients/3DD85723EF7538C14D898F80CDA760D4
Crome I and Williams R (editors) (2020) Part 5 Needs assessment, screening and diagnosis pp339-372 in Substance misuse and young people critical issues, London ; New York, Routledge https://www.taylorfrancis.com/books/substance-misuse-young-people-ilana-crome-richard-williams-roger-bloor-xenofon-sgouros/e/10.4324/9780429284304?refId=768c6aed-84cb-4b71-ac96-b935b9f35dde
Ghodse H (2010). Ghodse’s Drugs and Addictive Behaviour; a guide to treatment. 4thed, Cambridge University Press. Chapter 6 Assessment; Appendix 4 Hamid Ghodse Substance Abuse Assessment Questionnaire Appendix 7 & 8; Opiate Withdrawal; Appendix 9 Attendance Record
Saunders, John B. (et al.) (2021) Screening, Early Detection, and Brief Intervention of Alcohol Use Disorders pp 569-584 in Textbook of Addiction Treatment International Perspectives, eds. el-Guebaly, N., Carrà, G., Galanter, M., Baldacchino, A.M. Springer (https://www.springer.com/gb/book/9783030363901)
Effectiveness of brief alcohol interventions in primary care populations Kaner EFS, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N, Daeppen J, Saunders JB, Burnand B. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2018, Issue 2. Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.pub4 https://www.cochrane.org/CD004148/ADDICTN_effectiveness-brief-alcohol-interventions-primary-care-populations
Brief interventions to prevent excessive alcohol use in adolescents at low-risk presenting to Emergency Departments: Three-arm, randomised trial of effectiveness and cost-effectiveness https://www.sciencedirect.com/science/article/pii/S0955395921000128#
Drug misuse and dependence: UK guidelines on clinical management: How clinicians should treat people with drug misuse and drug dependence problems. https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management
Alcohol consumption: advice on low risk drinking: UK chief medical officers’ guidelines on how to keep health risks from drinking alcohol to a low level. https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking
May 18th 2021
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