Alcohol assessment: detailed clinical interview

Substance use history (alcohol and other drugs)

Start by asking these or similar questions:

• In a typical week:
  • On how many occasions would you drink alcohol?
  • How many drinks would you have?
•  How many times in the last year have you had more than six drinks?
• Has drinking alcohol ever caused problems for you?
• Have you ever been admitted to hospital because of an accident? How often?
• Has any close relative had alcohol problems?
• Would you get along better with a spouse/partner or close friends if you drank less?

Expand these questions to get a more complete picture of alcohol and other drug use, using specific questions to determine alcohol use and pattern of drinking more accurately.

Check that you have covered the following areas:

• frequency of drinking/drug taking
• quantity consumed
• pattern of consumption (i.e. binge, continuous)
• situational triggersduration of hazardous or harmful drinking/drug taking
• previous attempts to stop or cut down
• adverse consequences of substance use on family, work, social relationships, and health
• loss of control when using primary substance
• the patient’s perception of his or her substance use, both the need and perceived ability to change behaviour, e.g. ‘do you think your alcohol use is a problem?’

Additional areas to cover

• Substance career - when use started, pattern over time, when problems/withdrawal symptoms developed
• Substance consumption - how much in the last year, 6 months, week - What changes over this period?
• Substance related problems - ever, recently
• Other substance use - type, quantity, method of consumption, problems
• Abstinent periods - reason, duration, perceived support, outcome
• Previous treatment history - type of treatment, when previous treatment undertaken , method of treatment
• Forensic history - charges, convictions, imprisonment
• Occupational history - relationship of substance(s) use to job

Further assessment as appropriate:

• Personal history - developmental milestones, school, work, sexual, marital history and relationship to alcohol use
• Family history - parents’ and siblings’ age, relationship with patient, family history of substance use
• Sexual history - STD risk behaviour, needle sharing, unprotected sex, risk of pregnancy, effect of alcohol on these risks
• Marital history - general problems, sexual functioning problems, effect of drinking on these problems
• Present life situation - family/social supports, friends, job prospects It is important to ascertain the risk of harm to self or others (including suicide and suicide ideation, and risk with driving)

Specific assessment issues - ask these as appropriate:

Physical and sexual abuse

Some helpful questions:

• Do you feel safe in your current relationship?
• Have you always been safe in relationships?
• Have you ever been abused in a relationship - physically or sexually?

Comorbidity

These two questions have been found to effective screening for depression:

• Over the past two weeks, have you ever felt down, depressed or hopeless?
• Have you felt little interest or pleasure in doing things?

Positive responses indicate a need for further assessment.

Diagnosis of alcohol use disorders

Risk assessment:

Risk will vary depending on weekly consumption, episodes of heavy drinking and susceptibility to alcohol effects (based on age, sex, pregnancy, family history, medical and psychological problems, use of medication, nature of job).

DSM IV alcohol use classification

Alcohol use can be formally classified according to DSM IV criteria into a major category of alcohol dependence (mild, moderate or severe) and a residual category of alcohol abuse.

Alcohol Dependence:

The key features of the alcohol dependence syndrome are:

A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period:

1. tolerance, as defined by either:
   1. a need for markedly increased amounts of alcohol to achieve intoxication or the desired effect
   2. continued use of the same amount of alcohol with markedly diminished effect
2. withdrawal, as manifested by two or more of the following occurring after cessation or reduction of heavy prolonged alcohol use:
   1. autonomic hyperactivity such as sweating or heart rate in excess of 100 beats per minute
   2. hand tremor
   3. nausea or vomiting
   4. transient visual auditory or tactile hallucinations
   5. psychomotor agitation
   6. anxiety
   7. grand mal seizures
3.  alcohol is consumed in larger amounts or over a longer period than was intended
4.  there is a persistent desire or unsuccessful efforts made to cut down or control alcohol use
5.  a great deal of time is spent in activities necessary to obtain alcohol, consume it, or recover from its effects
6.  important social, occupational or recreational activities are given up or reduced because of alcohol use
7.  alcohol use is continued despite a physical or psychological problem that is likely to have been caused or exacerbated by the substance.

Alcohol Abuse:

The essential features of the abuse syndrome are:

A maladaptive pattern of alcohol use causing clinically significant distress or impairment of social or occupational functioning.

Maladaptive use will include high daily consumption, regular heavy weekend drinking, binge drinking (staying drunk for days, often after periods of abstinence).

One or more of the following must have occurred as a result of recurrent alcohol use within a 12 month period:

1. failure to fulfil major role obligations e.g. r e.g. repeated absences or poor work performance related to alcohol use; suspensions, or expulsions from school; neglect of the children or household
2. exposure to physical hazards e.g. driving an automobile or operating a machine when impaired by alcohol use.
3. legal problems e.g. arrests for alcohol-related disorderly conduct.
4. social or interpersonal problems e.g. arguments with partner about consequences of intoxication, physical fights whilst drunk.

A diagnosis of an abuse syndrome is not made if the person is dependent on alcohol.