History-taking in screening and assessment of substance use and addictive behaviours
Ask all new patients routinely and others (adolescents and adults) opportunistically and periodically about substance use and gambling. Disorders of substance use and gambling are common (and often co-exist) and people are reluctant to disclose these, often due to fear of stigma. Patients are more likely to disclose associated conditions such as anxiety, headaches, depression or hypertension, which can act as prompts for opportunistic enquiries. Ask also about video gaming in anyone presenting with potential harms of gaming.
Asking about substance use and gambling should be part of routine preventive health care. Framing a screening question as part of routine health screening can reduce stigma and increase the likelihood of disclosure. An approach to seeking permission for screening could be ‘Can I ask you some routine questions that I ask all my patients about habits that could affect your health? This includes things like exercise, nutrition, stress, weight, smoking, alcohol and other drugs and gambling. Is that OK?’
An approach to asking about these issues at follow-up visits could be framed as ‘We’ve spoken before about your drinking/smoking/gambling. How is that all going now?’
1 | In the past 3 months, did you smoke a cigarette containing tobacco? |
1a | Did you usually smoke more than 10 cigarettes each day? |
1b | Did you usually smoke within 30 minutes after waking? |
Risk category (total ‘yes’ answers) [NB3]: 0 = low; 1 or 2 = moderate; 3 = high | |
2 | In the past 3 months, did you have a drink containing alcohol? |
2a | On any occasion, did you drink more than 4 standard drinks of alcohol? |
2b | Have you tried and failed to control, cut down or stop drinking? |
2c | Has anyone expressed concern about your drinking? |
Risk category (total ‘yes’ answers) [NB3]: 0 or 1 = low; 2 = moderate; 3 or 4 = high | |
3 | In the past 3 months, did you use cannabis? |
3a | Have you had a strong desire or urge to use cannabis at least once a week or more often? |
3b | Has anyone expressed concern about your use of cannabis? |
Risk category (total ‘yes’ answers) [NB3]: 0 = low; 1 or 2 = moderate; 3 = high | |
4 | In the past 3 months, did you use an amfetamine-type stimulant, or cocaine, or a stimulant medication not as prescribed? |
4a | Did you use a stimulant at least once each week or more often? |
4b | Has anyone expressed concern about your use of a stimulant? |
Risk category (total ‘yes’ answers) [NB3]: 0 = low; 1 or 2 = moderate; 3 = high | |
5 | In the past 3 months, did you use a sedative or sleeping medication not as prescribed? |
5a | Have you had a strong desire or urge to use a sedative or sleeping medication at least once a week or more? |
5b | Has anyone expressed concern about your use of a sedative or sleeping medications? |
Risk category (total ‘yes’ answers) [NB3]: 0 = low; 1 or 2 = moderate; 3 = high | |
6 | In the past 3 months, did you use a street opioid (eg heroin) or an opioid-containing medication not as prescribed? |
6a | Have you tried and failed to control, cut down or stop using an opioid? |
6b | Has anyone expressed concern about your use of an opioid? |
Risk category (total ‘yes’ answers) [NB3]: 0 = low; 1 or 2 = moderate; 3 = high | |
7 | In the past 3 months, did you use any other psychoactive substances? |
If yes, what did you take? (Not scored, but prompts further assessment) | |
Note: NB1: An interactive and printable ASSIST-Lite tool is available for download at the AssistPortal. NB2: Versions of the questionnaire validated in people younger than 18 years (ASSIST-Youth 10 to 14 years or 15 to 17 years) are available at the ASSIST portal. NB3: Provide a brief intervention relevant to the risk category. Reproduced with permission from: Assist Portal. ASSIST-Lite: Alcohol, Smoking and Substance Involvement Screening Test. The University of Adelaide; Accessed September 2022. https://assistportal.com.au/resources/ | |
As an alternative to the ASSIST-Lite tool, substances and addictive behaviours to consider on initial screening include:
- nicotine (cigarettes, vaping products, chewing tobacco)
- alcohol
- cannabis (nonprescribed and prescribed forms1)
- stimulants (metamfetamine, ecstasy, cocaine)
- heroin, gamma-hydroxybutyrate (GHB), ketamine or lysergic acid diethylamide (LSD)
- prescription and over-the-counter drugs (eg opioids, benzodiazepines, zolpidem, zopiclone, pregabalin, gabapentin, quetiapine and other antipsychotics, sedating antihistamines2)
- other substances such as volatile inhalants (eg nitrous oxide, petrol, solvents, acetone, butane)
- gambling.
Ask also about video gaming in anyone presenting with potential harms of gaming.
- frequency of substance use (and method of ingestion) or addictive behaviours
- whether the person or anyone close to them is concerned about their use or behaviours
- motivations to use, gamble or game—see Brief interventions for helpful questions
- potential harms
- previous efforts to reduce substance use/gambling/gaming, including what did and did not work, withdrawal symptoms and their severity
- concurrent mental illness—for many people, their behaviour is driven by a wish to relieve symptoms or numb emotions; many also experience mental health harms
- possibility of pregnancy
- suicide risk, past history of overdoses, history of self-harm
- domestic violence and child protection considerationsGowing, 2014.
Diagnostic questionnaires can contribute to gathering information for screening and assessment; individual topics in these guidelines provide links.
If a person appears intoxicated or in withdrawal, keep the history-taking brief. Ask about withdrawal symptoms to help identify dependent use. Defer efforts to quantify use until the person is oriented, attentive and coherent. Exclude differential diagnoses of suspected intoxication or withdrawal, including precipitants of delirium, such as diabetic ketoacidosis, hypoglycaemia, infection and intracranial events.