# Evidence-based assessment/Substance use disorder (disorder portfolio)/extended version

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## What is a "portfolio?"

For background information on what assessment portfolios are, click the link in the heading above.
Does all of this feel like too much information? Click here to go to a condensed version of this page.

## Preparation Phase

   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.

### Demographic information

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of SUD that they are likely to see in their clinical practice.
We use "base rates," or benchmarks from other clinics and settings, to decide what we should be sure to get prepared to assess.

### Base rates of SUD in different populations and clinical settings

| Setting | Base Rate | Demography | Diagnostic Method |
| General population of North Carolina | 6.7% | North Carolina, aged 12 or older | National Survey on Drug Use and Health (NSDUH), 2009 to 2013 |
| United States General Adult Population: National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Grant et al., 2007) | 17.8 (0.5) Alcohol Abuse; 12.5 (0.4) Alcohol Dependence; 7.7 (0.2) Drug Abuse; 2.6 (0.1) Drug Dependence | 43,093 individuals, 18+ years old collected between 2001 and 2002 | National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule- DSM IV Version (AUDADIS-IV) |
| United States General Adult Population: National Comorbidity Survey Replication (NCS-R) | 13.2 (0.6) Alcohol Abuse; 5.4 (0.3) Alcohol Dependence; 7.9 (0.4) Drug Abuse; 3.0 (0.2) Drug Dependence | 9,282 adults, 18+ years old ; collected between 2001 and 2003 | 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 | 7.9% | New York, low-income primary care patients, 75% Hispanic, | Patient Health Questionnaire |
| Incarcerated females | 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 | 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 | 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 | 24.4% | Alleghany County, PA | Structured Clinical Interview for DSM-III-R |
| Internal medicine inpatients | 10.9% | Denmark | Symptom Check List (SCL-8) |

## Diagnosis
### Recommended diagnostic interviews

* Diagnostic Interview Schedule- IV
* Structured Clinical Interview for DSM-IV
* The Psychiatric Research Interview for Substance and Mental Disorders
* International Classification of Diseases, version 10
* The Mini International Psychiatric Interview (M.I.N.I)

### Screening instruments and diagnostic interviews

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Inter-rater reliability | Test-retest reliability | Construct validity | Content validity |
| Drug Abuse Screening Test (DAST) | Questionnaire | 18-adult | 5 minutes | NA | U | A | A |
| Drug Use Screening Inventory-Revised (DUSI-R) (not free) | Questionnaire | 10-18;18-adult | 20 minutes | NA | U | A | A |
| Structured Clinical International Diagnostic Interview (CIDI) | Interview | Adults | 30 minutes-3 hours | G | G | A | G |
| Substance Dependence Severity Scale (SDSS) | Interview | 16-adult | 30-45 minutes | NA | G | G | G |
| Global Appraisal of Individual Needs- Initial (GAIN-I) ($1.00 license fee per project for use of Beta version) | Interview | 12-adult | 1.5-2.5 hours | NA | G | G | G |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Prediction phase
### Psychometric properties of screening measures for SUD

| Screening Measure (Primary Reference) | AUC | LR+ (Score) | LR- (Score) | Clinical Generalizability |
| Timeline Follow Back | -- (N=113) | 6.82 | .0.28 | Moderate: The sample was drawn from 113 patients entering outpatient substance abuse treatment. |
| Bayesian Alcoholism Test | .989 (N=114) | 47 | .06 | Moderate: The BAT was tested against a broad spectrum of alcoholism in 114 male participants – heavy drinkers were measured against social drinkers – groups were further divided into treatment-seeking and non-treatment seeking. |
| Alcohol Use Disorder Identification Test (AUDIT) | .56 | 3.67 | .74 | Low: 120 Male VA outpatients 65 years or older |
| K6 Screening Scale (K6) | .84 (N=41,770) | 3.96 (13+) | .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) | .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. |
| Brief Screening for Alcohol, Tobacco, and Other Drugs (BSTAD) | 0.96 (N = 525) | 31.67 | .05 | Unsure- was administered in adolescents and no information is known about it’s utility in strictly clinical or adult populations. |
| Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD) | 0.6 (N = 201) | 1.86 | .82 | Low: validity assessed in 201 college students |
| Drug Abuse Screening Test (DAST) | .78 (N = 395) | 4.43 | 0.33 | Moderate: evaluated in a primary care setting of patients with psychiatric illness |
| CAGE | .70 (N = 358) | 1.86 | .49 | Questionable: sample was young adults 15-24 years attending urban clinic for sexually transmitted disease treatment and who reported alcohol use in the last year |
| Drug Use Disorders Identification Test (DUDIT) | 0.95 (N=153) | 6 | .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 .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .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

## Process phase

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

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. Disulfiram (250 mg/day), administered for one year, has been shown to help reduce drinking frequency after relapse. 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. 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
#### 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 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 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. 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. 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.

#### 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. 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.

## Process and Progress measures
### Severity and outcome
#### Clinically significant change benchmarks with common instruments and mood rating scales

| | | | Cut* Scores | Cut* Scores | Cut* Scores | Critical Change (Unstandardized Scores) | Critical Change (Unstandardized Scores) | Critical Change (Unstandardized Scores) |
| Measure | Measure | Measure | A | B | C | 95% | 90% | SE$_{difference}$ |
| Benchmarks Based on Published Norms |||||||||
| Rutgers Alcohol Problem Index (RUPI) | Rutgers Alcohol Problem Index (RUPI) | Rutgers Alcohol Problem Index (RUPI) | .8 | 4.9 | 4.0 | 4.1 | 3.5 | 2.1 |
| Alcohol Dependence Scale (copyrighted) | Alcohol Dependence Scale (copyrighted) | Alcohol Dependence Scale (copyrighted) | 1.2 | 9.9 | 7.8 | 1.4 | 1.2 | .7 |
| Drug Abuse Screening Test (DAST) | Drug Abuse Screening Test (DAST) | Drug Abuse Screening Test (DAST) | 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

## Web based resources

* National Institute on Drug Abuse
* Substance Abuse and Mental Health Services Administration (SAMHSA)
* The Addiction Recovery Guide
* EffectiveChildTherapy.Org information on Substance Abuse
* Society of Clinical Child and Adolescent Psychology