Recognition of Alcohol and Drug Abuse

Essentials

• Abuse of alcohol or drugs often causes health problems that make the user seek medical care, but the patients are nevertheless not able or willing to tell about the abuse. Every patient contact makes it possible to recognize the abuse and, in the best case, start treatment even at an early stage before severe harm occurs Brief Interventions for Risky Use of Alcohol.
• The best way to address the problem is to ask the patient directly, clearly and without judgement about the use. Observing clinical signs and discussing the findings with the patient helps in the assessment of the situation.
• Questionnaires, e.g. AUDIT Opportunistic Screening for Alcohol Use Disorders in Primary Care, can be used as assistive tools.
• If necessary, laboratory tests may be utilized.

Direct detection of alcohol or drug use

• Use of alcohol can be detected from the typical odour of the breath, by using a breath analyzer, or by assessing blood alcohol concentration.
• Use of drugs is detected from a urine sample with a qualitative screening panel. Depending on local legislation and other regulations, such drug testing may require the patient's permission (informed consent). When drug intoxication or abuse is suspected, more extensive investigations are required and the urine sample is sent to a specialized laboratory.
• There may be country-specific regulations concerning drug testing at the work place and the clinical use of drug tests.
• See also Brief interventions for risky use of alcohol Brief Interventions for Risky Use of Alcohol.

Symptoms induced by alcohol and drug abuse

• Various unspecific signs may suggest alcohol or drug abuse.
  • Absenteeism from work or school or decline in performance
  • Decline in general functioning, inability to concentrate
  • Behavioural disturbances in children and adolescents
  • Injection marks and infections at the injection sites
  • Intoxications, increased proneness to accidents
  • Sleeplessness and depression
  • Vague abdominal complaints and unexplainable pain
  • Problems with human relations in the private life or at work
  • Financial or housing problems
  • Demanding and manipulative conduct of the patient at the surgery
  • Elevated blood pressure, cardiac arrhythmias
• Acute symptoms include fluctuation in the level of consciousness and mood, hallucinations
  • Consider neurological and psychiatric disorders in the differential diagnostics.
• Note possible concurrent medical disorders such as a head injury, diabetes or an infection.

Structured interview concerning alcohol use

• AUDIT (Alcohol Use Disorders Identification Test) is the most recommended measure to assess excessive alcohol use Opportunistic Screening for Alcohol Use Disorders in Primary Care (see program Audit). It has a sensitivity of approximately 90%. The limit of risk use is 8 points for men and 6 points for women.
• In hectic out-of-hours settings, the third question of AUDIT (risk limit 2 points) or the AUDIT-C-version including only the first three questions (risk limit 6 points for men and 5 points for women) may be used.
• The alcohol tolerance of the body decreases by age. According to Finnish guidance, the average risk threshold doses for the elderly are at maximum 8 standard doses of alcohol in a week and 3 doses at any one time. One standard unit contains 12 g of absolute alcohol. Note that the point limits used in AUDIT are designed for working age persons.
• The patient can be encouraged to use internet-based self-assessment tests of alcohol problems: these may make it easier to take the problems up in a discussion. Relevant material may also be found within psychiatric evaluation forms.
• Several other tests are available, the majority of which are based on the Michigan Alcoholism Screening Test (MAST) The Validity of the Michigan Alcoholism Screening Test (Mast). An abridged version of this is called Veterans Administration Screening Test (VAST).
• When estimating the total amount consumed, it is advisable to ask about the different types of alcoholic drinks one by one (beer, cider, wine, spirits). It is often easier for a patient to describe questions that include words such as “can”, “bottle” or “pint”, instead of “dose”.

Laboratory tests and other measurements for detecting risky or excessive alcohol use

Applying a structured interview for assessing drug addiction

• Systematic interview with questions concerning specific substances and substance groups
  • Age of first use, appearance of problematic or compulsive use, attempts to stop the use or treat the problem, success of cessation attempts, etc.
• Less extensive tests that the patient can apply himself are, for example, the DAST-20 (Drug Abuse Screening Test, see e.g. http://adai.uw.edu/instruments/pdf/drug_abuse_screening_test_105.pdf http://socwel.ku.edu/sites/socwel/files/documents/Research%20Projects/Family%20First/Survey%20Measures/DAST%20Guide%202019%20-%20Remediated.pdf) and the SDS (Severity of Dependence Scale, see table T1). The higher the score is, the more serious is the dependence.
  • Both tests are well applicable in primary health care, as the patient can fill in the questionnaire in a few minutes.
  • May also be used in the assessment of the severity of dependence on pharmaceuticals
  • Also suited for monitoring long-term treatment response, in which case the total score should have a declining tendency
• Cannabis use disorders can be screened e.g. with the CAST questionnaire (Cannabis Abuse Screening Test) http://www.ofdt.fr/BDD/publications/docs/eisasst9.pdf http://kannabishanke.fi/wp-content/uploads/2020/11/Kannabishanke_Cast_ENG_MV.pdf. The probability of a cannabis use disorder is moderate if the score is 3-6 and high if the score is 7 or more.
• The use of more extensive questionnaires, such as the EuropASI (European Addiction Severity Index), requires basic instruction and training in their use.
  • EuropASI is suitable for a more comprehensive assessment of the patient's need for treatment and rehabilitation e.g. in units where the need for substitution therapy for opioid dependence is evaluated.