C.  Obtain A Comprehensive Biopsychosocial Assessment

OBJECTIVE

Identify the patient's current problems, relevant history, and life context as a basis for the integrated summary and initial treatment plan.

ANNOTATION

Include the following 10 general categories in a comprehensive assessment of SUDs (ASAM, 1996; Senay, 1997; Strauss, 1995):

1.        Patient's demographics and identifying information, including housing, legal, and occupational status

2.        Patient's chief complaint and history of the presenting complaint

3.        Recent substance use and severity of substance-related problems

4.        Lifetime and family history of substance use

5.        Co-morbid psychiatric conditions and psychiatric history

6.        Social and family context

7.        Developmental and military history

8.        Current medical status and medical history, including risk for HIV or hepatitis C

9.        Mental status and physical examinations

10.     Patient’s perspective on current problems and treatment goals or preferences

DISCUSSION

Assessment is the beginning of the therapeutic process.  The clinician's empathic and non-judgmental interest during assessment can help the patient make sense of his or her condition, decrease the patient’s sense of isolation, increase the likelihood of treatment adherence, and foster growth of the therapeutic alliance.  Conclusions from the assessment should be shared with the patient.  The clinician's attitude and manner are important components of the assessment process.  A nonjudgmental, respectful attitude that reflects genuine interest and empathy will facilitate rapport.  Reliability and validity of the assessment will be affected by the degree of trust in the interviewer and by consideration of the degree to which the patient presents voluntarily or feels coerced.  In determining reliability and validity of the assessment, the clinician should also recognize that recent substance use might affect the patient's presentation during the interview.  Memory and cognitive deficits and impairment of judgment and mood, secondary to drug use, may be present.  The clinician should monitor the patient's cognitive function and mental status during the assessment.  If it is possible to gain permission from the patient to do so, consulting with collateral informants (e.g., spouse/partner, family, friends, and/or co-workers) will provide a useful adjunct to gathering information directly from the patient.

The guidelines do not exclusively endorse the use of any particular instrument as the basis for a comprehensive assessment.  However, the Addiction Severity Index (ASI) (Fureman et al., 1990; McLellan et al., 1992) is a standardized, rater-administered interview that assesses seven functional domains considered important in an overall addiction evaluation: medical status, employment status, legal problems, family/social relations, drug use, alcohol use, and psychiatric status.  A computerized narrative summary is available when interview responses are entered into VistA (the VA centralized computer system) and may serve as the basis for the initial treatment plan.  Formal DSM-IV psychiatric diagnoses are derived from the clinical interview.