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

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What is a "portfolio?"[edit | edit source]

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

Want even 'more' information about this topic? There's an extended version of this page here.

Preparation Phase[edit | edit source]

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.
  • The diagnostic criteria for Substance Use Disorder disorder changed slightly from DSM-IV to DSM-5. Summaries are available here.

Base rates of SUD in different populations and clinical settings[edit | edit source]

Setting Base Rate Demography Diagnostic Method
General population of North Carolina, aged 12 or older 6.7% North Carolina National Survey on Drug Use and Health (NSDUH), 2009 to 2013
43,093 individuals, 18+ years old collected between 2001 and 2002[1] 17.8 (0.5) Alcohol Abuse; 12.5 (0.4) Alcohol Dependence; 7.7 (0.2) Drug Abuse; 2.6 (0.1) Drug Dependence United States General Adult Population: National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

(Grant et al., 2007)

National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule- DSM IV Version (AUDADIS-IV)
9,282 adults, 18+ years old ; collected between 2001 and 2003[2] 13.2 (0.6) Alcohol Abuse; 5.4 (0.3) Alcohol Dependence; 7.9 (0.4) Drug Abuse; 3.0 (0.2) Drug Dependence United States General Adult Population: National Comorbidity Survey Replication (NCS-R) 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, low-income primary care patients, 75% Hispanic[3] 7.9% New York Patient Health Questionnaire
Incarcerated females[4] 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[5] 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[6] 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[7] 24.4% Alleghany County, PA Structured Clinical Interview for DSM-III-R
Internal medicine inpatients[8] 10.9% Denmark Symptom Check List (SCL-8)

Prediction phase[edit | edit source]

Recommended screening instruments for SUD[edit | edit source]

Measure Format (Reporter) Age Range Administration/

Completion Time

Where to Access
Drug Use Screening Inventory-Revised (DUSI-R) [9][10] Self-report Teen and adult versions 20 minutes Contact Dr. Ralph Tarter at tarter@pitt.edu
Drug Abuse Screening Test (DAST)[11][12] Self-report Adolescents and Adults 10 minutes or less PDF
Alcohol Use Disorders Identification Test (AUDIT) [13][14][15] Self-report or interview 18+ 10 minutes or less PDF

Note: Reliability and validity are included in the extended version here. This table includes measures with Good or Excellent ratings.

Likelihood ratios and AUCs of screening measures for (insert portfolio name)[edit | edit source]

  • For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
Screening Measure (Primary Reference) AUC LR+ (Score) LR- (Score) Clinical Generalizability
Kessler 6 Screening Scale (K6) [16][17] 0.84

(N=41,770)

3.96

(13+)

0.296

(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)[18] 0.84

(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.
Drug Use Disorders Identification Test (DUDIT)[19] 0.95

(N=153)

6 0.12 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 0.1 are frequently clinically decisive; 5 or 0.2 are helpful, and between 2.0 and 0.5 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[edit | edit source]

Gold standard diagnostic interviews[edit | edit source]

  • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic interviews for substance use disorder[edit | edit source]

Diagnostic instruments for substance use disorder
Measure Format (Reporter) Age Range Administration/

Completion Time

Where to Access
The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS)[20][21] Structured interview 18+ Varies NIAAA
The Psychiatric Research Interview for Substance and Mental Disorders (PRISM)[22] Semi-structured 18+ 45 minutes to 2 hours Columbia Psychiatry
Structured Clinical Interview for DSM-V (SCID)[23] Semi-structured interview by trained clinician 18+ 1-2 hours -Available for purchase from APA Publishing (Note: Not free)

-Modified Version(not most recent version, SCID-I)

Global Appraisal of Individual Needs- Initial (GAIN-I) ($1.00 license fee per project for use of Beta version) [24] Semi-structured interview 12+ 1.5 to 2.5 hours MaterialsPDF
Composite International Diagnostic Interview (CIDI)[25] Structured interview by trained non-clinician 18+ 45 minutes to an hour WHO

Note: Reliability and validity are included in the extended version here. This table includes measures with Good or Excellent ratings.

Process phase[edit | edit source]

Outcome and severity measures[edit | edit source]

This table includes clinically significant benchmarks for (insert portfolio name here) specific outcome measures

  • Information on how to interpret this table can be found here.
  • Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
  • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.

Clinically significant change benchmarks with common instruments and mood rating scales

Clinically significant change benchmarks with common instruments and mood rating scales[edit | edit source]

Cut* Scores Critical Change
(Unstandardized Scores)
Measure A B C 95% 90% SEdifference
Benchmarks Based on Published Norms
Rutgers Alcohol Problem Index[26] [27] 0.8 4.9 4.0 4.1 3.5 2.1
Alcohol Dependence Scale (ADS)[26] (copyrighted) 1.2 9.9 7.8 1.4 1.2 0.7
Drug Abuse Screening Test (DAST) [28] 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

Treatment[edit | edit source]

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[edit | edit source]

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.[29] Disulfiram (250 mg/day), administered for one year, has been shown to help reduce drinking frequency after relapse.[30][31] 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.[32] 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[edit | edit source]

  • Cognitive Behavioral Therapies
    • 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[33] 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[34] 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.[35] 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
    • 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.[36] 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.[37]
  • Motivational Interviewing
    • 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.[38] 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.[39]

Web based resources[edit | edit source]

References[edit | edit source]

Click here for references
  1. Hasin DS, Grant BF. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Soc Psychiatry Psychiatr Epidemiol. 2015 Nov;50(11):1609-40. doi: 10.1007/s00127-015-1088-0. Epub 2015 Jul 26. PMID: 26210739.
  2. 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. 
  3. 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. 
  4. 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. 
  5. 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. 
  6. 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. 
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  13. Whittaker, Anne (2015-05). "Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy By World Health Organization Geneva, Switzerland: WHO Press, 2014ISBN: 9789241548731, 224 pp. Available free online http://www.who.int/substance_abu". Drug and Alcohol Review 34 (3): 340–341. doi:10.1111/dar.12212. ISSN 0959-5236. http://dx.doi.org/10.1111/dar.12212. 
  14. de Meneses-Gaya, Carolina; Zuardi, Antonio Waldo; Loureiro, Sonia Regina; Crippa, José Alexandre S. (2009-01). "Alcohol Use Disorders Identification Test (AUDIT): An updated systematic review of psychometric properties.". Psychology & Neuroscience 2 (1): 83–97. doi:10.3922/j.psns.2009.1.12. ISSN 1983-3288. http://doi.apa.org/getdoi.cfm?doi=10.3922/j.psns.2009.1.12. 
  15. Strobbe, Stephen (2014-06). "Prevention and Screening, Brief Intervention, and Referral to Treatment for Substance Use in Primary Care". Primary Care: Clinics in Office Practice 41 (2): 185–213. doi:10.1016/j.pop.2014.02.002. ISSN 0095-4543. http://dx.doi.org/10.1016/j.pop.2014.02.002. 
  16. 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. 
  17. 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
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  19. 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. 
  20. Samet, Sharon; Waxman, Rachel; Hatzenbuehler, Mark; Hasin, Deborah (2007-12). "Addressing Addiction: Concepts and Instruments". Addiction Science & Clinical Practice 4 (1): 19–31. doi:10.1151/ascp074119. ISSN 1940-0632. http://dx.doi.org/10.1151/ascp074119. 
  21. Üstün, B; Compton, W; Mager, D; Babor, T; Baiyewu, O; Chatterji, S; Cottler, L; Göğüş, A et al. (1997-09). "WHO Study on the reliability and validity of the alcohol and drug use disorder instruments: overview of methods and results". Drug and Alcohol Dependence 47 (3): 161–169. doi:10.1016/s0376-8716(97)00087-2. ISSN 0376-8716. http://dx.doi.org/10.1016/s0376-8716(97)00087-2. 
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  23. Samet, Sharon; Waxman, Rachel; Hatzenbuehler, Mark; Hasin, Deborah (2007-12). "Addressing Addiction: Concepts and Instruments". Addiction Science & Clinical Practice 4 (1): 19–31. doi:10.1151/ascp074119. ISSN 1940-0632. http://dx.doi.org/10.1151/ascp074119. 
  24. Hunsley, John; Mash, Eric J., eds (2018-06). "A Guide to Assessments That Work". Oxford Clinical Psychology. doi:10.1093/med-psych/9780190492243.001.0001. http://dx.doi.org/10.1093/med-psych/9780190492243.001.0001. 
  25. Üstün, B; Compton, W; Mager, D; Babor, T; Baiyewu, O; Chatterji, S; Cottler, L; Göğüş, A et al. (1997-09). "WHO Study on the reliability and validity of the alcohol and drug use disorder instruments: overview of methods and results". Drug and Alcohol Dependence 47 (3): 161–169. doi:10.1016/s0376-8716(97)00087-2. ISSN 0376-8716. http://dx.doi.org/10.1016/s0376-8716(97)00087-2. 
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  32. 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. 
  33. 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. 
  34. Villagrá Lanza, P; González Menéndez, A (2013). "Acceptance and Commitment Therapy for drug abuse in incarcerated women.". Psicothema 25 (3): 307-12. PMID 23910743. 
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  36. al.], Scott W. Henggeler ... [et (2012). Contingency management for adolescent substance abuse : a practitioner's guide. New York, NY: Guilford Press. ISBN 1462502474. 
  37. 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. 
  38. Miller, William R.; Rollnick, Stephen (2013). Motivational interviewing : helping people change (3rd ed.). New York, NY: Guilford Press. ISBN 1609182278. 
  39. 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.