Diagnosis of Drug and Alcohol Abuse: An Overview

Diagnosis is the process of identifying and labeling specific disease conditions. Diagnostic criteria are standardized groups of signs and symptoms used to decide whether an individual has a particular disease or not. If a person has a certain number of symptoms from the list of possible criteria, then the diagnosis can be made. Once a diagnosis is made, the health-care provider and patient can begin to make decisions about appropriate treatment.

Mental health professionals often treat patients who abuse drugs or alcohol. By consulting diagnostic manuals, medical professionals can make accurate diagnoses of substance use disorders, such as abuse or dependence . They can evaluate signs and symptoms (for example, acute intoxication , withdrawal , and delirium, or mental confusion), and laboratory data (such as blood alcohol content or liver function tests) and use these as a basis for planning treatment.

Two reference works, the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders, are periodically revised to reflect important research findings that affect the accurate diagnosis of various conditions. Alcoholism and drug addiction have been defined at various times as medical diseases, mental disorders, social problems, and behavioral conditions.

Patient Histories

One of the first steps toward treating a person with substance use problems is to ask the individual for a history of drug and alcohol use. Unfortunately, patients with alcohol and drug problems often do not provide accurate information about their own past or present use. They are often embarrassed by or ashamed of their substance abuse, or are afraid of getting themselves into trouble with the law. Although they want help for the medical complications of substance abuse (such as injuries or depression), they may not be ready to give up alcohol or drug use entirely. Many people provide only a hazy picture of their behavior, hiding the full extent of their alcohol or drug use. Therefore, the medical professional obtaining a patient's history must be highly skilled, non-threatening, nonjudgmental, and very perceptive.

Taking a history of a person's illness usually follows a standard approach. This consists of:

• identifying the chief complaint
• evaluating the present illness
• reviewing past history
• reviewing physical functioning (such as blood pressure and cardiovascular health)
• asking about family history of similar disorders
• discussing the patient's psychological health and how well he or she is getting along with others in society.

A history of the present illness usually begins with questions about the use of alcohol, drugs, and tobacco. The questions should cover prescription drugs as well as illicit drugs, and the kinds of drugs used, the amount used, and the way the drug was taken (smoking, injection, and so on). Questions about alcohol use should refer specifically to the amount and frequency of use of major types (wine, spirits, beer). A thorough physical examination is important, because each substance has specific effects on certain organs and body systems. For example, alcohol can affect the liver, stomach, and cardiovascular systems. Drugs often produce abnormalities in vital signs such as temperature, pulse, and blood pressure. Evidence of substance use disorders can often be seen in the person's mental state. For example, poor personal hygiene, an inappropriate mood (sad, euphoric , irritable, anxious), illogical thought processes, and memory problems can all be symptoms of disorders.

The physical examination can be followed by laboratory tests, which sometimes aid in early diagnosis before severe or irreversible damage has taken place. Many drugs can be detected in the urine for twelve to forty-eight hours after their consumption. An estimate of blood alcohol concentration can be made directly by blood test or indirectly by means of a breath or saliva test. Elevated levels of a liver enzyme, gamma glutamyl transpeptidase, can indicate liver damage from chronic , heavy alcohol intake.

Diagnosing Dependence

There are three essential features of dependence on substances: (1) the development of tolerance ; (2) the presence of withdrawal symptoms when the drug dose is lowered or drug use is stopped; and (3) compulsive use of a substance.

Tolerance. Tolerance occurs when a person must take increasing amounts of a drug to obtain the effects originally produced by lower doses. Physical tolerance involves changes in a person's cellular functioning. Alcoholics can drink amounts of alcohol (such as a quart of vodka) that would be sufficient to incapacitate or kill nontolerant drinkers. Tolerance can also be psychological. An example of psychological tolerance is when the marijuana smoker or heroin user no longer experiences a "high" after the initial dose of the substance.

Withdrawal. Withdrawal is characterized by a group of symptoms that occur when a person stops taking a drug or lowers the dose. Some common minor withdrawal symptoms are restlessness, fatigue, and an inability to sleep. More serious withdrawal symptoms include hallucinations and depression . Some drugs, such as marijuana and hallucinogens, do not typically produce a withdrawal syndrome after use is stopped.

Withdrawal symptoms from alcohol occur within hours after a person has stopped drinking. These include shaking, rapid heartbeat, increased blood pressure, nausea, and vomiting. In some cases, patients may also have seizures or hallucinations. In addition to physical withdrawal symptoms, anxiety and depression are also common. Some chronic drinkers never have a long enough period of abstinence to permit withdrawal to occur.

Using a substance to relieve withdrawal symptoms is a clear sign of physical dependence. For example, taking a drink of alcohol in the morning to relieve nausea or the "shakes" is one of the most common signs of physical dependence in alcoholics.

Compulsive Use. Compulsive use of a substance refers to an individual's failure to abstain from using the substance, in spite of the negative consequences of that use. For example, an alcoholic may want to stop drinking, but—despite repeated attempts—he or she is unable to do so. Not only can the individual not stop using the drug, he or she cannot even regulate the amount of alcohol or drug consumed on a given occasion. For instance, the cocaine addict vows to snort only a small amount, but then continues until the entire supply is used up. Or the alcoholic cannot stop drinking before becoming intoxicated.

Diagnosing Substance Abuse

Substance abuse is different from substance dependence. The criteria for substance abuse do not include tolerance, withdrawal, or a pattern of compulsive use. Instead, the major criterion for substance abuse is harmful use of a substance. The harm can be physical (such as fatty liver or hepatitis) or psychological (such as depression). A diagnosis of substance abuse can also be made in the case of hazardous use of a substance, such as driving while under the influence of alcohol or drugs.

The diagnosis of abuse is designed mainly for people who have recently begun to experience alcohol or drug problems, and for chronic users who do not show symptoms of dependence. For example, a diagnosis of substance abuse might be made in these cases:

• A pregnant woman who keeps drinking alcohol even though her physician has told her that it could damage the fetus.
• A college student whose weekend binges result in missed classes, poor grades, or alcohol-related traffic accidents.
• A middle-aged beer drinker who regularly drinks a six-pack each day and develops high blood pressure and fatty liver but no symptoms of dependence.
• An occasional marijuana smoker who has an accidental injury while intoxicated.

Diagnostic Tests

Physicians and researchers use various approaches to identify and assess people who may be abusing drugs or alcohol. One approach is to use brief screening instruments or tests—usually self-report questionnaires—to determine the possible presence of substance use disorders.

CAGE. One test that is commonly used to screen adults for alcohol abuse and/or dependence is called CAGE, which consists of four simple questions (asking about signs of compulsive use and withdrawal):

1. Have you ever felt the need to c ut down on your drinking?
2. Do you get a nnoyed at criticism by others about your drinking?
3. Have you ever felt g uilty about your drinking or something you have done while drinking?
4. Have you ever felt the need for a drink early in the morning (or as an "e ye opener")?

Answering "yes" to two or more items on the CAGE questionnaire suggests the presence of problem drinking (and possibly dependence).

MAST. The Michigan Alcoholism Screening Test includes twenty-five items that help determine symptoms and consequences of a person's alcohol use. Items include information about guilt regarding drinking habits; experiences with blackouts following drinking; symptoms of delirium tremens (a delirium with tremors and shaking); loss of control; family, social, employment, and legal problems following bouts of drinking; and help-seeking behaviors (such as attending Alcoholics Anonymous meetings or going into a hospital due to drinking). There are also shorter questionnaires that are based on the MAST, including the 13-item Short-MAST and the 10-item Brief-MAST.

SeeSee Organizations of Interest at the back of Volume 1 for address, telephone, and URL.

SMST. The Self-Administered Alcoholism Screening Test is a 35-item questionnaire that uses yes-or-no questions to try to define the probability that a person is an alcoholic.

ADS. The Alcohol Dependence Scale can help define how severely dependent an individual is on alcohol. This test covers questions that explore an individual's inability to control his or her drinking (compulsion), episodes of withdrawal, and loss of control due to drinking.

T-ACE. Heavy maternal drinking is a major pregnancy risk and a significant public health problem. Babies born with fetal alcohol syndrome may have facial deformities and an abnormal brain. To address the problem of drinking during pregnancy, a screening test, known as the T-ACE, was developed to determine which mothers are most at risk. The T-ACE is a brief, simple questionnaire given to women by health-care providers. It is similar to the CAGE test, in that it also asks about a nnoyance (by others), attempts to c ut down on alcohol use, and its use as an "e ye opener" in the morning. However, instead of g uilt, it asks about the number of drinks needed to feel the effects of alcohol, which can indicate the presence of t olerance.

The Drug Abuse Screening Test. The Drug Abuse Screening Test (DAST) is a questionnaire designed to indicate drug-related problems in certain groups of people, such as psychiatric patients, prison inmates, and employees in a workplace. The DAST takes approximately five minutes to administer and may be given as a written questionnaire or as an oral interview. The person taking the test is instructed that "drug abuse" refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions and (2) any nonmedical use of drugs. The drugs include marijuana, solvents or glue, tranquilizers, cocaine, LSD, and heroin. The questions do not include alcohol.

Diagnosing Adolescents

Adolescents are different from adults not only because their bodies are still developing, but also because they tend to live under quite different circumstances than adults do. For example, most of them are not yet married, they still attend school, and do not yet have full-time jobs. As a result, many of the questions contained in screening tests used to diagnose substance abuse in adults are not applicable to teenagers. Therefore, some of these tests have been modified—and some new ones have been developed—for use with this particular age group.

DAST-A. The DAST-A is a modified version of the DAST. It is a 27-item self-report screening instrument that directly asks adolescents about any negative consequences they may have had as a result of drug use. The DAST-A is very similar to the DAST; however, some questions have been changed to make them more relevant to an adolescent population. Instead of asking about spousal concerns, for instance, there are questions about concerns expressed by parents, boyfriends, or girlfriends. Similarly, items about work-related issues have been changed into questions referring to possible problems occurring at school.

RAFFT. The RAFFT test is a simple screening tool developed specifically to identify adolescents who may be abusing alcohol or drugs. It uses the following five questions:

1. Do you drink or take drugs to r elax, feel better about yourself, or fit in?
2. Do you ever drink or take drugs while you are a lone?
3. Do any of your closest f riends drink or take drugs?
4. Does a close f amily member have problems with alcohol or drugs?
5. Have you gotten into t rouble from drinking or taking drugs?

Other Tests for Adolescents. Many other tests have also been developed besides the above to screen adolescents for potential drug or alcohol abuse or dependence. One of these is the Personal Experience Screening Questionnaire, which is a relatively long (40-item) questionnaire that has been designed to measure the severity or degree of any alcohol or drug use problem by a teenager. Other commonly used tests include the Adolescent Alcohol Involvement Scale, the Adolescent Drinking Index, and the Rutgers Alcohol Problem Index.

Screening tests like these can help doctors and therapists determine if a person has been abusing drugs or alcohol. However, these instruments by themselves cannot be relied on to arrive at a diagnosis of substance abuse or dependence. Physicians must be well trained to recognize the signs and symptoms of drug abuse, and they should use their professional judgment to make an accurate diagnosis. Once they have done that, they can go on to the next step, which is to offer appropriate treatment to those in need.

see also entries on specific drugs; Addiction: Concepts and Definitions; Drug Testing Methods and Analysis; Fetal Alcohol Syndrome (FAS); Risk Factors for Substance Abuse.

THE HOLD OF DRUGS

One sign of addiction is that the drugs come to mean more than anything else in the user's life. I wanted a new experience, said Sean, a 17-year-old who is recovering from his addiction to cocaine. He recalls how the drug took over his life:

The only thing on my mind was coke. I was forgetting all of my other responsibilities and losing friends quick. I was only hanging out with those five people [who I did coke with]. I wasn t going to school.