Chapter 7 Screening and Assessment
Screening And Assessment Starting the dialogue and begin relationship Each are sizing each other up Information gathering Listening to their story Asking the questions at the right time Assessing Stage of Change Information giving Normalizing Statistics Assessment (CSAT) (2005) Process for defining the nature of the problem and developing specific treatment recommendations for addressing the problem.
Screening and Assessment Advantages of doing assessment: Get information Match to counselor Get insurance reimbursement for diagnosis Disadvantages: May set up false expectations for specialized treatment Delays actual treatment May be inappropriate for many minority groups
Screening Vs Assessment Screening Quickly assess the possibility of a problem Assessment Identity addiction problem Focus on what s going on in client s life An opportunity to gather specific information about why client entering tx Focus on what the client wants to be different Information gathered to create a treatment plan Document for one clinician to communicate with other clinicians
Treatment Plan Collaboration between client and clinician Focus on specific behaviors and needs of the client Create interventions to reduce symptoms Create plan to meet client needs Address ASAM criteria: Withdrawal detox Biomedical medical services Cognitive MI treatment Tx motivation Level of Care Relapse potential Level of Care Environment Level of Care Family education Referrals
CAGE C Have you ever felt you ought to cut down on your drinking or drug use? A Have people annoyed you by criticizing your drinking or drug use? G Have you ever felt bad or guilty about your drinking or drug use? E Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover? (Eye Opener) Scoring one point for each yes 2 yes response = problematic
TWEAK Tolerance Worried Eye Openers Amnesia Kut down
AUDIT The AUDIT includes 10 items that cover: Amount and frequency of drinking Alcohol dependence symptoms Personal problems Social problems Scoring discriminates between different levels of risk Hazardous Harmful Possible dependence Can be given as a questionnaire or used as interview questions. Available for free on the Internet.
AUDIT 1. How often do you have a drink containing alcohol? (0) Never (Skip to Questions 9-10) (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) 4 or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7, 8, or 9 (4) 10 or more 3. How often do you have six or more drinks on one occasion? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
AUDIT 4. How often during the last year have you found that you were not able to stop drinking once you had started? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 5. How often during the last year have you failed to do what was normally expected from you because of drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 6. How often during the last year have you been unable to remember what happened the night before because you had been drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
AUDIT 7. How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 8. How often during the last year have you had a feeling of guilt or remorse after drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year 10. Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year
Scoring for Audit Scores for questions 1 through 8 range from 0 to 4: The first response for each question (never)score 0 The second (less than monthly) score 1 The third (monthly) score 2 The fourth (weekly) score 3 Last response ( daily or almost daily) score 4 Questions 9 and 10: (have three responses): score 0, 2, and 4 TOTAL SCORE INTERPRETATION: A score of 8 or more is associated with harmful or hazardous drinking. A score of 13 or more in women is likely to indicate Substance Use Disorder, Severe. A score of 15 or more in men, is likely to indicate Substance Use Disorder, Severe.
MAST The Michigan Alcohol Screening test (MAST) self-scoring test The original MAST was a 25-item questionnaire. Now a 22-item questionnaire.
The SASSI Substance Abuse Subtle Screening Inventory (SASSI) Miller & Lazowski, 1999 The SASSI Institute A different approach to assessment instruments Does not ask directly about substance misuse on one side of the form Consists of true-false items: I am often resentful. I like to obey the law.
SASSI 3 subscales also evaluate: Attitude toward assessment Ability to acknowledge problems Defensiveness Risk of legal problems Emotional pain SASSI A2 (Adolescents) SASSI Social system impact on substance use Attitudes toward substance use Level of acknowledgement Emotional pain Risk of acting-out behavior Substance Use Disorder, Mild, Moderate or Severe
DrInC The Drinker Inventory of Consequences (DrInC) Originally designed for Project MATCH A 50-item questionnaire that covers: Physical Social Intrapersonal Impulse control Interpersonal problem areas Positive questions such as How often has drinking helped me to relax? Negative questions: How often has my ability to be a good parent been harmed by my drinking.
Mental Health and Substance Use Mentally Ill and Substance user (MISA) Dual diagnosis Co-occurring disorder (COD)
Guidelines for Assessment of Dual Dx Be familiar with latest DSM and criteria for diagnosis. Keep up to date on the relevant psychiatric medications. Know the community resources.
Assessment of Older Clients Risk factors for gambling problems are: Posttraumatic stress disorder symptoms Minority race or ethnicity Being a Veterans Affairs (VA) patient CAGE and MAST Geriatric version
ASSESSMENT FOR STRENGTHS View clients as in charge of their own goals. Social and individual factors for a comprehensive view. Move the assessment toward strengths Intrapersonal: Motivation Emotional strengths Ability to think clearly Interpersonal: Family Support networks, etc. Avoid identifying the person with a label.
Strengths Assessment continued Key ingredients: Empathy. Provide hope. Reflective listening.
5 Stages of Chemical Dependence Stage 1: Learn Mood Swing Stage 2: Seek Mood Swing Stage3: Substance Use Disorder Mild- Moderate Stage 4: Substance Use Disorder Moderate- Severe Stage 5: Death
The Eleven Symptoms of Alcohol Use Disorder 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. 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. 10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol b) Alcohol (or related substance, i.e.. benzo) taken to relieve or avoid withdrawal symptoms. Mild: 2 to 3 symptoms Moderate: 4 to 5 symptoms Severe: 6 or more symptoms
Early full remission 1 month but less than 12 Remission No criteria for abuse or dependence Early partial remission - 1 month but less than 12 one or more criteria for abuse or dependence Sustained full remission None of the criteria for abuse or dependence in 12 month period or longer Sustained partial remission Full criteria for dependence not met for 12 or more months 1 or more criteria for dependence or abuse have been met
Withdrawal A substance-specific syndrome Due to the cessation of (or reduction in) substance use That has been heavy and prolonged. The syndrome causes clinically significant distress or impairment in: Social, Occupational or Other important areas of functioning. The symptoms are not due to a General medical condition and Are not better accounted for by another mental disorder.
CiWA-Ar (clinical Institute withdrawal assessment for Alcohol) 1.Nausea and vomiting 2.Tremor 3.Paroxysmal sweats 4.Anxiety 5.Agitation 6.Tactile disturbances 7.Auditory disturbances 8.Visual disturbances 9.Headaches or fullness in head
Levels of Care Prevention Education Dare Level.5 - Early Intervention- SAP programs Experimental use Level I Outpatient Substance Use Disorder, Mild/Moderate Level II Intensive Out Patient (IOP) Substance Use Disorder, Moderate/Severe High motivation Able to abstain Level III Inpatient Substance Use Disorder, Severe Low motivation Toxic environment Level IV - Detox
Levels of Care Detox 3-7 days Stabilize; reduce withdrawal symptoms Outpatient I session per week 20 hours Intensive Out Patient Adolescent = 6-9 hours per week Adult = 12-15 hours per week 75 hours More structure than out patient Less interference than residential Followed by aftercare Inpatient Structured 2 weeks to 2 years 75+ hours Risk of harm Risk of relapse Followed by IOP, half way house, aftercare Aftercare once a month Last leg of treatment tour ; may be treatment, 12 Step group or religious activity
Levels of Care
American Society of Addiction Medicine (ASAM) 1. Withdrawal Risk of withdrawal symptoms 2. Biomedical Medical issues that my interfere with treatment 3. Cognitive- Mental health issues that my interfere with treatment 4. Motivation How motivated to change What stage of change 5. Relapse How many times tried to quit? Successful? 6. Environment Using peers/family Conflict with family