IDENTIFICATION OF SUBSTANCE MISUSE
All health and social care workers are in a position to identify and help people with drug and alcohol problems. A large proportion of visits to primary care are related to such problems, as are medical and psychi- atric admissions. Questions about drug and alcohol misuse are most appropriately asked as part of the wider history, leading on from smoking and caffeine use. Such questions should be asked in an open and non-judgmental manner so as to avoid engendering defensiveness in the patient.
The most commonly used screening tool is the CAGE questionnaire which has a sensitivity of 60 to 95% (correct identification rate if there is a problem) for alcohol/drug problems, and a specificity of 40 to 95% (correct exclusion rate if there is no problem). (Beresford, Blow et al., 1990). The CAGE can be used for either alcohol or drug problems e.g. Have you ever felt the need to cut down your cannabis use?
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- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticising your drinking.
- Have you ever felt bad or Guilty about your drinking?
- Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
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- Have you ever had a problem with alcohol (drugs)?
- Have you had any alcohol (drugs) in the last 24 hours?
If both responses are positive the likelihood of a current problem is very high (Cyr & Wartman 1988). It is important to ask the CAGE before progressing to more detailed questioning on amounts of substance misuse, as its sensitivity may be diminished if asked after these questions (Steinweg & Worth 1993).
After the CAGE has been administered, progress to ascertaining the frequency and amount of substances consumed in the last week. The responses should be analysed in the context of the WHO guidelines for safe drinking limits (21 units weekly for males, 14 units weekly for females). There are no recommendations for safe limits of illicit substance use. Units of alcohol in a drink can be calculated by this simple equation:
Units of alcohol in a drink = volume (l) x % alcohol by volume
E.g.A 3/4l bottle of whisky which is 40% abv contains 30 units of alcohol.
Apart from the above standardised screening process, there are a number of 'red flags' indicative of possible underlying problems with drug or alcohol misuse. An awareness of the various symptoms and signs of intoxication and withdrawal will enable detection in some cases (appendix 3, page 117). Equally, there are various 'indirect' complaints that are commonly associated with problematic substance misuse:
- Frequent absences from work or school.
- History of frequent accidental injuries.
- Depression.
- Anxiety.
- Gastrointestinal symptoms.
- Sexual dysfunction.
- Sleep disorders.
- Mild tremor.
- Alcoholic foetor
(smell of alcohol on the breath). - 'Aftershave/Mouthwash syndrome' . Anxiety. (to mask the odour of alcohol).
- Enlarged, tender liver.
- Nasal irritation
(suggestive of cocaine insufflation). - Conjunctival irritation
(suggestive of marijuana smoking). - Fluctuating hypertension
(high blood pressure). - Tachycardia and/or cardiac arrythmias.
Family members may present with emotional distress secondary to physical abuse and children with abdominal pains, headaches or school problems. In short, the list of suggestive features is enormous. The overriding principle of identification must be to remain alert to the possibility that a drug or alcohol problem may be hidden behind the presenting complaint - the above screening process should then be implemented as appropriate. This is just as important in the elderly as in the young; there is a growing body of epidemiological evidence that alcohol disorders in particular are far more prevalent in older populations than was previously recognised (Reid M, Anderson P, 1997).
Direct identification of substances may also aid in the identification of a substance misuse problem. Photographs of the commonly abused substances can be found on the cover of this manual.
Laboratory and on-site screening tests may also aid in identification of a problem. A table of the commonly used tests and the interpretation of the results is available in appendix 5, page 121.
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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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