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Evidence-based assessment/Substance use disorder (disorder portfolio)/extended version

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EBA Implementation
Assessment phases
Steps 1-2: Preparation phase

Preparation phase

Steps 3-5: Prediction phase

Prediction phase

Steps 6-9: Prescription phase

Prescription phase

Steps 10-12: Process/progress/outcome phase

Process phase

What is a "portfolio?"

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For background information on what assessment portfolios are, click the link in the heading above.

Does all of this feel like too much information? Click here to go to a condensed version of this page.

Preparation Phase

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Diagnostic Criteria for Substance Use Disorder ICD-11 Diagnostic Criteria for Substance Use Disorder

  • Disorders due to substance use and addictive behaviours are mental and behavioural disorders that develop as a result of the use of predominantly psychoactive substances, including medications, or specific repetitive rewarding and reinforcing behaviours.
    • Note: The ICD-11 lists 20 additional subcategories of Substance Use Disorder. They can be found here.

DSM Diagnostic Criteria for Substance Use Disorder

  • Substance use disorder is a DSM disorder in the Substance-Related and Addictive Disorders chapter. It is characterized by the use of substances in a manner that leads to clinically significant impairment or distress.


Demographic information

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This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of SUD that they are likely to see in their clinical practice.

We use "base rates," or benchmarks from other clinics and settings, to decide what we should be sure to get prepared to assess.

Base rates of SUD in different populations and clinical settings

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Setting Base Rate Demography Diagnostic Method
General population of North Carolina 6.7% North Carolina, aged 12 or older National Survey on Drug Use and Health (NSDUH), 2009 to 2013
United States General Adult Population: National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

(Grant et al., 2007)

17.8 (0.5) Alcohol Abuse; 12.5 (0.4) Alcohol Dependence; 7.7 (0.2) Drug Abuse; 2.6 (0.1) Drug Dependence 43,093 individuals, 18+ years old collected between 2001 and 2002 National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule- DSM IV Version (AUDADIS-IV)
United States General Adult Population: National Comorbidity Survey Replication (NCS-R)[1] 13.2 (0.6) Alcohol Abuse; 5.4 (0.3) Alcohol Dependence; 7.9 (0.4) Drug Abuse; 3.0 (0.2) Drug Dependence 9,282 adults, 18+ years old ; collected between 2001 and 2003 World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) which generates DSM-IV and International Classification of Diseases, 10th revision diagnoses
Urban General Medicine Practice[2] 7.9% New York, low-income primary care patients, 75% Hispanic, Patient Health Questionnaire
Incarcerated females[3] 70.2% Chicago prison - 40 % African American, 33% White, 25 % Hispanic National Institute of Mental Health Diagnostic Interview Schedule Version 11I-R (NIMH DIS-III-R)
Incarcerated females (updated)

(Proctor 2012)

70% dependent Minnesota State Prison System- 801 females, 18-58 years old, 57.7% Caucasian, 21.5% African American, 13.2% Native American Substance Use Disorder Diagnostic Schedule-IV (SUDDS-IV)
Incarcerated male youths[4] 56.4% Texas state prison – 45 % African American, 33% White, 20% Hispanic Structured Clinical Interview for DSM IV – Substance Use Disorders Module
Individuals with schizophrenia across settings[5] 47% New Haven, CT; Baltimore, MD; St. Louis, MO; Durham, NC; Los Angeles, CA National Institute of Mental Health (NIMH) Diagnostic Interview Schedule
HIV+ men in community health clinics[6] 24.4% Alleghany County, PA Structured Clinical Interview for DSM-III-R
Internal medicine inpatients[7] 10.9% Denmark Symptom Check List (SCL-8)

Diagnosis

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  • Diagnostic Interview Schedule- IV
  • Structured Clinical Interview for DSM-IV
  • The Psychiatric Research Interview for Substance and Mental Disorders
  • International Classification of Diseases, version 10
  • The Mini International Psychiatric Interview (M.I.N.I)[8]

Screening instruments and diagnostic interviews

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Measure Format (Reporter) Age Range Administration/

Completion Time

Inter-rater reliability Test-retest reliability Construct validity Content validity
Drug Abuse Screening Test (DAST) Questionnaire 18-adult 5 minutes NA U A A
Drug Use Screening Inventory-Revised (DUSI-R) (not free) Questionnaire 10-18;18-adult 20 minutes NA U A A
Structured Clinical International Diagnostic Interview (CIDI) Interview Adults 30 minutes-3 hours G G A G
Substance Dependence Severity Scale (SDSS) Interview 16-adult 30-45 minutes NA G G G
Global Appraisal of Individual Needs- Initial (GAIN-I) ($1.00 license fee per project for use of Beta version) Interview 12-adult 1.5-2.5 hours NA G G G

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Prediction phase

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Psychometric properties of screening measures for SUD

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Screening Measure (Primary Reference) AUC LR+ (Score) LR- (Score) Clinical Generalizability
Timeline Follow Back[9] --

(N=113)

6.82 .0.28 Moderate: The sample was drawn from 113 patients entering outpatient substance abuse treatment.
Bayesian Alcoholism Test[10] .989

(N=114)

47 .06 Moderate: The BAT was tested against a broad spectrum of alcoholism in 114 male participants – heavy drinkers were measured against social drinkers – groups were further divided into treatment-seeking and non-treatment seeking.
Alcohol Use Disorder Identification Test (AUDIT) [11][12] .56 3.67 .74 Low: 120 Male VA outpatients 65 years or older
K6 Screening Scale (K6)[13][14] .84

(N=41,770)

3.96

(13+)

.296

(0-12)

High: The sample of 41,770 was drawn from initial surveys that were carried out in 14 countries.
Alcohol, Smoking and Substance Involvement Screening Test(ASSIST) [15] .84

(N=1,047)

2.76 0.28 High: The sample of 1,047 participants was drawn from drug treatment and primary health care settings in Australia, Brazil, India, Thailand, the United Kingdom, the U.S. and Zimbabwe.
Brief Screening for Alcohol, Tobacco, and Other Drugs (BSTAD)[16] 0.96

(N = 525)

31.67 .05 Unsure- was administered in adolescents and no information is known about it’s utility in strictly clinical or adult populations.
Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD)[17] 0.6

(N = 201)

1.86 .82 Low: validity assessed in 201 college students
Drug Abuse Screening Test (DAST) [18] .78

(N = 395)

4.43 0.33 Moderate: evaluated in a primary care setting of patients with psychiatric illness
CAGE [19] .70

(N = 358)

1.86 .49 Questionable: sample was young adults 15-24 years attending urban clinic for sexually transmitted disease treatment and who reported alcohol use in the last year
Drug Use Disorders Identification Test (DUDIT)[20] 0.95

(N=153)

6 .12 High: 153 participants from outpatient and residential substance use treatment programs

Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000).

Search terms: [substance use OR substance use disorders] AND [sensitivity OR specificity] in Google Scholar and PsycINFO

Prescription phase

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Process phase

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In the United States, according to SAMHSA, of the 8.9 million adults with a dual diagnosis, 44% received some form of treatment in the past year. Given the frequent co-occurrence of mood disorders and substance use disorders, the recommended first step in treatment is for clinicians to deliver a comprehensive screening evaluation that will inform their treatment approach. There are a host of empirically supported treatments for substance use disorders, though medication interventions and psychotherapy are most common.

Medication

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Specifically, medications have been shown to be most effective in the treatment of alcohol and opioid dependence. Naltrexone (50 mg/day) administered for 12 weeks has been shown to decrease cravings for alcohol and the number of days in which alcohol was consumed.[21] Disulfiram (250 mg/day), administered for one year, has been shown to help reduce drinking frequency after relapse.[22][23] In the context of opioid dependence, Methadone has been the gold standard medication treatment for over 30 years.

According to numerous studies, patients on higher doses of methadone (>50mg/day) report less illicit opioid use, as well as increased retention rates in treatment.[24] Buprenorphine is an alternative to Methadone to treat opioid dependence and research similarly supports its clinical efficacy. Buprenorphine (60 mg/day) has been shown to bring about improved retention rates, as well as reduced illicit opioid use.

Therapy

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Cognitive Behavioral Therapies

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While medication serves as an effective intervention for some with drug dependence, behavioral interventions are also empirically supported. A number of studies suggest that CBT is an effective intervention for substance use. In a 2010 review, McHugh, Hearon and Otto[25] found that CBT for substance use, which synthesizes cognitive and motivational elements, as well as skills-building interventions, is effective both as a stand-alone treatment and when combined with other treatments. Acceptance and Commitment Therapy (ACT) has also been used to treat substance-using populations with encouraging results. Specifically, Lanza and Menéndez[26] employed a 16-session ACT in the treatment of incarcerated females. In this population, abstinence rates, as well as anxiety sensitivity and other comorbid psychopathology showed improvement. Another behavior intervention that has been successfully implemented is Mindfulness Therapy for Substance Use.[27] Research indicates that this modality is effective across a range of populations through use of methods that help patients to develop nonreactive, acceptance behaviors.

Contingency Management

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One common technique implemented as a treatment method across psychiatric disorders is contingency management, wherein the problematic behavior of the individual is closely monitored and reinforcers are delivered contingent upon detection of a target behavior.[28] In the case of substance use, abstinence is monitored via urine screens or other objective methods and the patient is rewarded for abstinence through prizes or vouchers, which are conversely withheld in the event that the patient does not remain abstinent as determined by urine screening or related methods. Recent work has demonstrated that contingency management can be an effective method for delaying time to first use after treatment and achieving short-term sobriety in individuals with substance use disorders. However, the effects of this intervention seem to be contingent upon the magnitude of the reward, and effects are not evident long-term.[29]

Motivational Interviewing

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Motivational Interviewing is a treatment option that seems to be particularly useful for individuals who are ambivalent about changing behavior. This type of intervention requires the therapist to build a collaborative relationship with the patient, using empathic and non-confrontational approaches to help the patient enhance personal motivation to change.[30] Finally, behavioral activation therapy attempts to address comorbid diagnoses commonly occurring with substance use disorders (i.e., depression) in an attempt to improve outcomes for individuals who may be harder to treat. This technique aims to increase positive reinforcers and decrease intensity and occurrences of negative consequences and life events. This treatment approach has been effective in reducing severity of depression and anxiety symptoms, and increasing enjoyment and reward value of posttreatment activities as compared to treatment as usual.[31]

Process and Progress measures

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Severity and outcome

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Clinically significant change benchmarks with common instruments and mood rating scales

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Cut* Scores Critical Change
(Unstandardized Scores)
Measure A B C 95% 90% SEdifference
Benchmarks Based on Published Norms
Rutgers Alcohol Problem Index (RUPI)[32] [33] .8 4.9 4.0 4.1 3.5 2.1
Alcohol Dependence Scale[32] (copyrighted) 1.2 9.9 7.8 1.4 1.2 .7
Drug Abuse Screening Test (DAST) [34] 0.1 2.6 1.8 1.6 1.3 0.8

Note: "A" = Away from the clinical range, "B" = Back into the nonclinical range, "C" = Closer to the nonclinical than clinical mean.

Search terms: [substance use OR substance use disorder] AND [clinical significance OR outcomes] in Google Scholar and PsycINFO

Web based resources

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References

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Click Expand for references
  1. ↑ Kessler, RC; Green, JG; Gruber, MJ; Sampson, NA; Bromet, E; Cuitan, M; Furukawa, TA; Gureje, O et al. (June 2010). "Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative.". International journal of methods in psychiatric research 19 Suppl 1: 4-22. PMID 20527002. 
  2. ↑ Olfson, M; Shea, S; Feder, A; Fuentes, M; Nomura, Y; Gameroff, M; Weissman, MM (NaN). "Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice.". Archives of family medicine 9 (9): 876-83. PMID 11031395. 
  3. ↑ Teplin, LA; Abram, KM; McClelland, GM (June 1996). "Prevalence of psychiatric disorders among incarcerated women. I. Pretrial jail detainees.". Archives of general psychiatry 53 (6): 505-12. PMID 8639033. 
  4. ↑ Wasserman, GA; McReynolds, LS; Lucas, CP; Fisher, P; Santos, L (March 2002). "The voice DISC-IV with incarcerated male youths: prevalence of disorder.". Journal of the American Academy of Child and Adolescent Psychiatry 41 (3): 314-21. PMID 11886026. 
  5. ↑ Regier, DA; Farmer, ME; Rae, DS; Locke, BZ; Keith, SJ; Judd, LL; Goodwin, FK (21 November 1990). "Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study.". JAMA 264 (19): 2511-8. PMID 2232018. 
  6. ↑ Dew, MA; Becker, JT; Sanchez, J; Caldararo, R; Lopez, OL; Wess, J; Dorst, SK; Banks, G (March 1997). "Prevalence and predictors of depressive, anxiety and substance use disorders in HIV-infected and uninfected men: a longitudinal evaluation.". Psychological medicine 27 (2): 395-409. PMID 9089832. 
  7. ↑ Hansen, MS; Fink, P; Frydenberg, M; Oxhøj, M; Søndergaard, L; Munk-Jørgensen, P (April 2001). "Mental disorders among internal medical inpatients: prevalence, detection, and treatment status.". Journal of psychosomatic research 50 (4): 199-204. PMID 11369025. 
  8. ↑ Sheehan, DV; Lecrubier, Y; Sheehan, KH; Amorim, P; Janavs, J; Weiller, E; Hergueta, T; Baker, R et al. (1998). "The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.". The Journal of clinical psychiatry 59 Suppl 20: 22-33;quiz 34-57. PMID 9881538. 
  9. ↑ Fals-Stewart, W; O'Farrell, TJ; Freitas, TT; McFarlin, SK; Rutigliano, P (February 2000). "The timeline followback reports of psychoactive substance use by drug-abusing patients: psychometric properties.". Journal of consulting and clinical psychology 68 (1): 134-44. PMID 10710848. 
  10. ↑ Korzec, A; de Bruijn, C; van Lambalgen, M (October 2005). "The Bayesian Alcoholism Test had better diagnostic properties for confirming diagnosis of hazardous and harmful alcohol use.". Journal of clinical epidemiology 58 (10): 1024-32. PMID 16168348. 
  11. ↑ Bush, K; Kivlahan, DR; McDonell, MB; Fihn, SD; Bradley, KA (14 September 1998). "The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test.". Archives of internal medicine 158 (16): 1789-95. PMID 9738608. 
  12. ↑ Morton, J. L., Jones, T. V., & Manganaro, M. A. (1996). Performance of alcoholism screening questionnaires in elderly veterans. The American journal of medicine, 101(2), 153-159.
  13. ↑ Kessler, RC; Green, JG; Gruber, MJ; Sampson, NA; Bromet, E; Cuitan, M; Furukawa, TA; Gureje, O et al. (June 2010). "Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative.". International journal of methods in psychiatric research 19 Suppl 1: 4-22. PMID 20527002. 
  14. ↑ Swartz, J. A., & Lurigio, A. J. (2006). Screening for serious mental illness in populations with co-occurring substance use disorders: Performance of the K6 scale. Journal of substance abuse treatment, 31(3), 287-296
  15. ↑ Humeniuk, R; Ali, R; Babor, TF; Farrell, M; Formigoni, ML; Jittiwutikarn, J; de Lacerda, RB; Ling, W et al. (June 2008). "Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST).". Addiction (Abingdon, England) 103 (6): 1039-47. PMID 18373724. 
  16. ↑ Kelly, Sharon M.; Gryczynski, Jan; Mitchell, Shannon Gwin; Kirk, Arethusa; O’Grady, Kevin E.; Schwartz, Robert P. (2014-05-01). "Validity of Brief Screening Instrument for Adolescent Tobacco, Alcohol, and Drug Use". Pediatrics 133 (5): 819–826. doi:10.1542/peds.2013-2346. ISSN 0031-4005. PMID 24753528. http://pediatrics.aappublications.org/content/133/5/819. 
  17. ↑ Kills Small, Nancy J.; Simons, Jeffrey S.; Stricherz, Mathias. "Assessing criterion validity of the Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD) in a college population". Addictive Behaviors 32 (10): 2425–2431. doi:10.1016/j.addbeh.2007.04.003. https://doi.org/10.1016/j.addbeh.2007.04.003. 
  18. ↑ Hearon, Bridget A.; Pierce, Casey L.; Björgvinsson, Thröstur; Fitzmaurice, Garrett M.; Greenfield, Shelly F.; Weiss, Roger D.; Busch, Alisa B. (March 2015). "Improving the efficiency of drug use disorder screening in psychiatric settings: validation of a single-item screen". The American Journal of Drug and Alcohol Abuse 41 (2): 173–176. doi:10.3109/00952990.2015.1005309. ISSN 1097-9891. PMID 25700005. https://www.ncbi.nlm.nih.gov/pubmed/25700005. 
  19. ↑ Cook, Robert L.; Chung, Tammy; Kelly, Thomas M.; Clark, Duncan B. (2005-01-01). "Alcohol screening in young persons attending a sexually transmitted disease clinic". Journal of General Internal Medicine 20 (1): 1–6. doi:10.1111/j.1525-1497.2005.40052.x. ISSN 0884-8734. https://link.springer.com/article/10.1111/j.1525-1497.2005.40052.x. 
  20. ↑ Voluse, Andrew C.; Gioia, Christopher J.; Sobell, Linda Carter; Dum, Mariam; Sobell, Mark B.; Simco, Edward R.. "Psychometric properties of the Drug Use Disorders Identification Test (DUDIT) with substance abusers in outpatient and residential treatment". Addictive Behaviors 37 (1): 36–41. doi:10.1016/j.addbeh.2011.07.030. https://doi.org/10.1016/j.addbeh.2011.07.030. 
  21. ↑ Volpicelli, JR; Alterman, AI; Hayashida, M; O'Brien, CP (November 1992). "Naltrexone in the treatment of alcohol dependence.". Archives of general psychiatry 49 (11): 876-80. PMID 1345133. 
  22. ↑ Chick, J; Gough, K; Falkowski, W; Kershaw, P; Hore, B; Mehta, B; Ritson, B; Ropner, R et al. (July 1992). "Disulfiram treatment of alcoholism.". The British journal of psychiatry : the journal of mental science 161: 84-9. PMID 1638335. 
  23. ↑ Fuller, RK; Branchey, L; Brightwell, DR; Derman, RM; Emrick, CD; Iber, FL; James, KE; Lacoursiere, RB et al. (19 September 1986). "Disulfiram treatment of alcoholism. A Veterans Administration cooperative study.". JAMA 256 (11): 1449-55. PMID 3528541. 
  24. ↑ Farrell, M; Ward, J; Mattick, R; Hall, W; Stimson, G; Des Jarlais, D; Gossop, M; Strang, J (1994.). "Methadone maintenance treatment in opiate dependence: a review.". British Medical Journal 309 (6960): 997. 
  25. ↑ McHugh, RK; Hearon, BA; Otto, MW (September 2010). "Cognitive behavioral therapy for substance use disorders.". The Psychiatric clinics of North America 33 (3): 511-25. PMID 20599130. 
  26. ↑ Villagrá Lanza, P; González Menéndez, A (2013). "Acceptance and Commitment Therapy for drug abuse in incarcerated women.". Psicothema 25 (3): 307-12. PMID 23910743. 
  27. ↑ Marcus, Marianne T.; Zgierska, Aleksandra (27 October 2009). "Mindfulness-Based Therapies for Substance Use Disorders: Part 1". Substance Abuse 30 (4): 263–265. doi:10.1080/08897070903250027. 
  28. ↑ al.], Scott W. Henggeler ... [et (2012). Contingency management for adolescent substance abuse : a practitioner's guide. New York, NY: Guilford Press. ISBN 1462502474. 
  29. ↑ Petry, NM; Alessi, SM; Barry, D; Carroll, KM (June 2015). "Standard magnitude prize reinforcers can be as efficacious as larger magnitude reinforcers in cocaine-dependent methadone patients.". Journal of consulting and clinical psychology 83 (3): 464-72. PMID 25198284. 
  30. ↑ Miller, William R.; Rollnick, Stephen (2013). Motivational interviewing : helping people change (3rd ed.). New York, NY: Guilford Press. ISBN 1609182278. 
  31. ↑ Daughters, SB; Braun, AR; Sargeant, MN; Reynolds, EK; Hopko, DR; Blanco, C; Lejuez, CW (January 2008). "Effectiveness of a brief behavioral treatment for inner-city illicit drug users with elevated depressive symptoms: the life enhancement treatment for substance use (LETS Act!).". The Journal of clinical psychiatry 69 (1): 122-9. PMID 18312046. 
  32. ↑ 32.0 32.1 Roberts, LJ; Neal, DJ; Kivlahan, DR; Baer, JS; Marlatt, GA (June 2000). "Individual drinking changes following a brief intervention among college students: clinical significance in an indicated preventive context.". Journal of consulting and clinical psychology 68 (3): 500-5. PMID 10883566. 
  33. ↑ White, HR; Labouvie, EW (January 1989). "Towards the assessment of adolescent problem drinking.". Journal of studies on alcohol 50 (1): 30-7. PMID 2927120. 
  34. ↑ Skinner, HA (1982). "The drug abuse screening test.". Addictive behaviors 7 (4): 363-71. PMID 7183189. 
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