Assessing Alcohol Dependence and Drug Abuse

First you take a drink, then the drink takes a drink, then the drink takes you.

–F. Scott Fitzgerald

In an initial diagnostic interview, you will probably not have time to do a complete assessment of the history, extent, and consequences of a patient’s substance abuse problem. Such an assessment requires a full session in itself. What, then, are your more limited goals? There are three:

Determine whether your patient meets DSM-IV criteria for alcohol/drug dependence or abuse.
Get a sense of the severity of the problem.
Determine how the alcohol use interacts with any comorbid psychiatric disorders present.

The most important tip for beginners is to be nonjudgmental. This requires some soul-searching because most of us have negative prejudices about substance abusers, and we tend to see them as being morally suspect. Be aware of the extent to which you hold such attitudes, and evaluate whether they are accurate. Try to meet with recovered alcoholics. Their stories
are often poignant and will help you to develop a more sympathetic and compassionate attitude. Learn about the disease model of alcoholism (Clark 1981). The more you can view alcoholism as similar to the other psychiatric disorders you treat, the fewer prejudices you will retain.

ASSESSMENT TECHNIQUES

Screening Questions

TIP

The best quick screen for alcoholism remains the tried-and-true CAGE questionnaire (see below; Ewing 1984), in which a positive response to two or more of the items implies a 95% chance of alcohol abuse or dependence. However, one study (Steinweg 1993) suggests that the way interviewers transition to the CAGE questions profoundly affects the questionnaire’s sensitivity. Researchers divided 43 confirmed alcoholics into two groups. In group I, the CAGE was introduced with an open-ended question, such as “Do you have a drink now and then?” In group II, patients were first asked to quantitate their alcohol intake with the question, “How much do you drink?” Sensitivity toward the CAGE questions was dramatically higher in group I (95%) than in group II (32%), demonstrating the importance of beginning the screening in a nonjudgmental way.

CAGE questionnaire:

Cut down: “Have you felt you should cut down on your drinking?”

Annoyed: “Have people annoyed you by getting on your case about your drinking?”

Guilty: “Have you ever felt bad or guilty about your drinking?”

Eye-opener: “Have you ever needed to take a drink first thing in the morning to steady your nerves or get rid of a hangover?”

Begin your screen with the nonthreatening question:

Do you enjoy a drink now and then?

If a patient answers, “I never drink,” you should ask, “Why not?” Most people of the American culture have a drink occasionally; people who make a point of not drinking are uncommon. They may avoid drinking because they are
recovered alcoholics, because they have a family member with a serious drinking problem, or for religious or ethical reasons. Most people will answer with something like, “Oh, I have glass of wine with dinner,” or “I have a beer when I barbecue.”

Once you have ascertained any use of alcohol of other substances, jump right into the CAGE questions:

Cut down: Have you ever tried to cut down on your drinking?

A cardinal feature of alcoholism is the loss of control over drinking, and this question gets at that issue. If the patient answers “yes,” follow up with

What made you decide to cut down?

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