Substance Abuse and Dependence Health Article

Diagnosis

Tools used in the diagnosis of substance dependence include screening questionnaires and patient histories, physical examination, and laboratory tests. A simple and popular screening tool is the CAGE questionnaire. CAGE refers to the first letters of each word that forms the basis of each of the four questions of the screening exam:

• have you ever tried to Cut down on your substance use?
• have you ever been Annoyed by people trying to talk to you about your substance use?
• do you ever feel Guilty about your substance use?
• do you ever need an Eye opener (use of the substance first thing in the morning) in order to start your day?

A "yes" answer to two or more of these questions is an indication that the individual should be referred for more thorough work-up for substance dependency or abuse.

In addition to CAGE, other screening questionnaires are available. Some are designed for particular population groups such as pregnant women, and others are designed to more thoroughly assess the severity of substance dependence. These questionnaires, known by their acronyms, include AUDIT, HSS, HSQ, PRIME-MD, ACE, TWEAK, s-MAST, and SADD. There is some variability among questionnaires in terms of how accurately and comprehensively they can identify individuals as substance dependent.

Patient history, as taken through the direct interview, is important for identifying physical symptoms and psychiatric factors related to substance use. Family history of alcohol or other substance dependency is also useful for diagnosis.

A physical examination may reveal signs of substance abuse. These signs are specific to the substances used, as well as needle marks, tracks, or nasal erosion.

With the individual's permission, substance use can be detected through laboratory testing of his or her blood, urine, or hair. Laboratory testing, however, may be limited by the sensitivity and specificity of the testing method, and by the time elapsed since the person last used the drug.

One of the most difficult aspects of diagnosis involves overcoming the patient's denial. Denial is a psychological state during which a person is unable to acknowledge the (usually negative) circumstances of a situation. In this case, denial leads a person to underestimate the degree of substance use and of the problems associated with substance use.

Treatment

According to the American Psychiatric Association, there are three goals for the treatment of persons with substance use disorders: (1) the patient abstains from or reduces the use and effects of the substance; (2) the patient reduces the frequency and severity of relapses; and (3) the patient develops the psychological and emotional skills necessary to restore and maintain personal, occupational, and social functioning.

In general, before treatment can begin, many treatment centers require that the patient undergo detoxification. Detoxification is the process of weaning the patient from his or her regular substance use. Detoxification can be accomplished "cold turkey, " by complete and immediate cessation of all substance use, or by slowly decreasing (tapering) the dose which a person is taking, to minimize the side effects of withdrawal. Some substances must be tapered because "cold turkey" methods of detoxification are potentially life threatening. In some cases, medications may be used to combat the unpleasant and threatening physical and psychological symptoms of withdrawal. For example, methadone is used to help patients adjust to the tapering of heroin use.

Treatment itself consists of three parts: (1) assessment; (2) formulation of a treatment plan; (3) psychiatric management. The first step in treatment is a comprehensive medical and psychiatric evaluation of the patient. This evaluation includes:

• a history of the patient's past and current substance use, and its cognitive, psychological, physiological, and behavioral effects
• a medical and psychiatric history and examination
• a history of psychiatric treatments and outcomes
• a family and social history
• screening of blood, breath, or urine for substances
• other laboratory tests to determine the presence of other conditions commonly found with substance use disorders

After the assessment is made, a treatment plan is formulated. Treatment plans vary according to the needs of the specific patient and can change for the same patient as he or she undergoes different phases of the disorder. Plans typically involve the following elements: (1) a strategy for the psychiatric management of the patient;(2) a strategy for reducing effects or use of substances, or for abstinence; (3) efforts to ensure compliance with the treatment program and to prevent relapse; (4) treatments

for other conditions associated with substance use. Initial therapy and treatment setting (hospital, residential treatment, partial hospitalization, outpatient) decisions are made as part of the treatment plan, but because substance use disorders are considered a chronic condition requiring long-term care, these plans can and do change through the course of treatment.

The third step, psychiatric management of the patient, is the implementation of the treatment plan. Psychiatric management of the patient includes establishing a trusting relationship between clinician and patient; monitoring the patient's progress; managing the patient's relapses and withdrawal; diagnosing and treating associated psychiatric disorders; and helping the patient adhere to the treatment plan through therapy and the development of skills and social interactions that reinforce a drug-free lifestyle.

As part of the treatment process, patients typically undergo psychosocial therapy and, in some cases, pharmacologic treatment. Psychosocial therapeutic modalities include cognitive-behavioral therapy, behavioral therapy, individual psychodynamic or interpersonal therapy, group therapy, family therapy, and self-help groups. Pharmacologic treatment may include medications that ease withdrawal symptoms, reduce craving, interact negatively with substances of abuse to discourage drug-taking, or treat associated psychiatric disorders.