Documenting Substance Use and Potential for Withdrawal

One of the critical elements in evaluating individuals with a substance use disorder is assessing and documenting their substance use (Mee, Lee, Shulman, Fishman, & Gastfriend, 2013; Ries, Fiellin, Miller, & Saitz, 2014; US Department of Health and Human Services, 2004). The chart in Table 1 is the most concise way of performing the assessment and documenting the results. 

[INSERT TABLE 1 HERE]

Let’s go over completing the chart. 

There are two basic models for this chart. In the first, the drug name blocks are left blank and it is up to the clinician to fill them in. The advantage of this model is that it has the flexibility to note the ever-changing drug scene. The disadvantage is that the assessor must be cognizant of all of the patterns of drug use in incoming patients.

In the second model, the blocks have preprinted drug names that make the assessment easier but the disadvantage is that once it is printed, “it is written in stone.” The final block in the preprinted drug list, “Other,” is of limited assistance unless the assessor is conversant with the substance use patterns of the patients being assessed. For example, a drug usually not found in most preprinted drug lists is dextromethorphan, the active ingredient in “Vicks 44” and Robitussin-DM, drugs of abuse among adolescents and young adults.

Route of administration can provide us with a plethora of information about the patient. Patients who inject drugs via IV are at risk for acquiring blood borne diseases such a HIV/AIDS or hepatitis B or C. Because smoking a drug is the most efficient route of administration of a substance, these drugs tend to be used more compulsively and achieving recovery may be more difficult (e.g., tobacco and crack cocaine). Cocaine addicts who use crack cocaine tend to use cocaine for longer periods or episodes (“runs”) and thereby need to acquire more cocaine than powder cocaine users and therefore they are more likely to engage in illegal activities to finance their greater needs for larger amounts of cocaine. These could include drug dealing, burglary, robbery, and/or prostitution. Smoking a drug is the most efficient route of administration having an effect on the brain in less than ten seconds. This is one of the reasons why stopping smoking cigarettes is so difficult, even for individuals who have recovered from other addictions. This is also complicated by the much more frequent dosing (e.g., every ten to twenty seconds) versus the dosing for IV use of an opioid (e.g., approximately every four hours). Smoking a drug is usually done more compulsively and may be associated with more difficult recovery.

Although uncommon, we must also consider route of administration for alcohol. An anesthesiologist addicted to alcohol spent most of the period prior to admission for treatment using alcohol IV and not the anesthetics to which he had access. Inhaling alcohol vapors is occasionally found among college students who wish to get the effect of the drug without the calories they would get if they drank. This is very dangerous because it bypasses the nausea response to drinking a large quantity of alcohol that may result in a fatal overdose. 

First use is usually not important unless it co-occurs with first problem, which can be used to illustrate to the patient the length of time of their substance use. 

This is important in conveying to patients the length of their substance use problems. For those whose substance-related problems began at earlier ages, it is reasonable to assume that the progression of the disorder was (or will be in adolescents) more rapid and possibly more severe. When the addictive disorder begins at an early age, the normal process of emotional development and coping skill acquisition is arrested so that when patients begin the recovery process they find the process more daunting.

Amount is very important in determining the potential for withdrawal problems. Obtaining an accurate picture of intake amount poses a real challenge depending on the beverage used and the setting. For individuals who make their own cocktails or drink directly out of a bottle, determining amount is most difficult. For beer drinkers, it is important to ask what size beer—a pony is only seven ounces and at the other end of individual beer containers is the forty ounce bottle of beer or malt liquor, which has a higher alcohol content and contains more alcohol than three twelve ounce bottles or cans, and even more if it is malt liquor. Always ask whether there is a beer “chaser” for a distilled spirits drink. If the patient’s pattern is to drink distilled spirits (e.g., “shots”), you should ask if they are singles or doubles and whether they “chase it” with another alcoholic drink such as a beer.

Impress upon patients, particularly beer drinkers, that a twelve ounce bottle or can of beer, a five ounce glass of wine, and 1.5 ounce drink of distilled spirits all contain equivalent amounts of alcohol.

Frequency of use is asked for a number of reasons. Frequency (chronicity) provides information on the severity of the substance use disorder. If the frequency has been daily with little or no intervening periods of abstinence, there is no recent history of withdrawal severity because the patient has not stopped long enough for full withdrawal to have occurred (e.g., the daily drinker versus the individual who drinks large quantities only on the weekends). Also, if the frequency has been daily with little or no intervening periods of abstinence, the body has had little or no opportunity to heal itself.

Documenting last use is commonly done inadequately. The most common “time” documented for last use is in days, as in “yesterday,” but for drugs with a short half-life, time should be listed as last use on the clock as well as days. For example, the last use listed for an alcohol dependent patient as yesterday at 12:01 AM yesterday versus yesterday at 11:59 PM is a period of almost twenty-four hours, which constitutes a significant risk for withdrawal for those using a substance with a short half-life. A note of caution: when asking these questions, rather than asking “Do you use?” ask “Have you ever used?” This is particularly true because many perceive themselves as not using if they haven’t used today.

Capacity is another way of asking about tolerance, but asking directly about tolerance is likely to generate a response from patients that they “love everyone.” The closer the current use is to the maximum capacity/tolerance in the past, the more likely the individuals are to have severe withdrawal problems. For example, maximum tolerance by history is a fifth of distilled spirits a day for a three-day period and now patients are drinking the same quantities versus the same history of tolerance but patients are currently drinking only half a pint per day.

When asking questions on the form without preprinted drug names, begin with the drug assumed to be the drug of choice based on the initial interaction between assessor and patient. Once the assessor feels that all of the pertinent information about that substance has been elicited, move on to other substances. The best way of proceeding is by drug class. Do not ask, “Do you use any other drugs?” but instead ask, “What other drugs do you use?” The latter question implies universality. Continue this process through all of the drug categories including over-the-counter drugs. Do not forget to do the same thing with tobacco products.

In addition to all of the above information, ask about previous withdrawal symptoms. If, for example, individuals who have an alcohol use disorder have never suffered withdrawal seizures, it is unlikely that they would experience this time. In contrast, if there is a history of seizures, seizures in current withdrawal are much more likely.

After all of the drug use information has been obtained, complete the items on the last line of the form.

It is possible that after the initial impression of drug of choice, a different drug of choice becomes apparent as a result of the continuing assessment. Most adults with substance use disorders have a drug of choice but will use other drugs if their drug of choice in unavailable or to manage withdrawal symptoms. A common example is the street use of buprenorphine to treat withdrawal symptoms associated with legal or illicit opioids. Adolescents may not have yet decided on a drug of choice and availability is a key driver in drug choice. 

When asking about the longest period of abstinence, also ask about other drug use during that time.  For example, individuals with an alcohol use disorder who report a six-month period of abstinence from alcohol, but were using benzodiazepines throughout that time, has been abstinent only from their drug of choice. That six-month period provides little information about their ability to remain abstinent or their risk of severe withdrawal.

    

A year of total substance abstinence that occurred ten years ago is not as significant as one that occurred last year. If patients have been previously treated for a substance use disorder, the presence or absence of total abstinence following treatment can be used as an indicator of their ability to benefit from treatment. The absence of previous treatment conveys no predictive value about how they would fare in their first treatment.

It is at this point we are assessing the circumstances surrounding any periods of abstinence that patients may have had. If patients state that they had a period of one year during which they had been totally abstinent and the circumstance was that they had been imprisoned, this is not predictive of their ability to remain abstinent outside of a controlled environment—although they deserve congratulations when we understand the sometimes use of homemade alcohol and illicit use of contraband legal and illegal drugs in prison. If we find that outside of a controlled environment, patients have not be able to remain abstinent for more than twenty-four hours in the last two years, referring them to an ASAM Level 1 outpatient program that meets once/week or an ASAM Level 2.1 IOP program that meets three times per week, is a prescription for failure.

The information collected by using the chart in Table 1 not only provides data about ASAM Dimension 1 Acute Intoxication and/or Withdrawal Potential, but may also inform the assessment in other dimensions such as Dimension 2: Biomedical Conditions and Complications, for blood-borne diseases associated with IV drug use; Dimension 5, Relapse, Continued Use and Continued Problem Potential, for ability to remain abstinent.

The primary value of this system is the ability to document a large amount of information in a concise manner.

Mee, Lee, D., Shulman, G. D., Fishman, M. J., & Gastfriend, D. (Eds.). (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring disorders (3rd ed.). Carson City, NV: The Change Companies.

Ries, R. K., Fiellin, D. A., Miller, S. C., & Saitz, R. (2014). The ASAM principles of addiction medicine (5th ed.). Philadelphia, PA: Wolters Kluwer.

US Department of Health and Human Services. (2004). Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A treatment improvement protocol (TIP) 40. Retrieved from http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf