Welcome to the American Osteopathic Academy of Addiction Medicine's Learning Management System. This is an educational and efficient way to learn the essentials of addiction medicine. This presentation is on the assessment of patients with substance use disorders. Your narrator is Dr. Gregory Landy, and I will be with you throughout this particular presentation. There are three broad objectives that you will learn during this particular presentation. You will be introduced to the DSM-5 criteria, which is an essential part of what we're going to be learning. If you're not familiar with the acronym SBIRT, you'll become familiar with this evidence-based practice as we proceed through this particular presentation. And finally, we're going to spend some time talking about alcohol and drug laboratory testing, which again is an essential part. Pictured here is the Diagnostic and Statistical Manual of Mental Disorders, otherwise affectionately known as DSM-5. Now, it may seem redundant to actually review the DSM-5, but for a presentation that is exploring the assessment of substance use disorders, it really makes perfect sense to begin with an overview of DSM-5 and the diagnostic classifications that it provides. Let's begin with some of the important changes that were added to DSM-5. Now, it might seem a minor point, but DSM-5 no longer uses Roman numerals. It moved to the more modern Arabic numeration system. But for those of us that are familiar with the previous versions of the Diagnostic and Statistical Manual, there was a multi-axial diagnostic system. We had an Axis 1 through 5, Axis 1 with the primary diagnosis, and Axis 2 typically with the personality disorder diagnosis, and so on. That was all eliminated in DSM-5. For some individuals, this might seem controversial, but nonetheless, this is DSM-5. The current iteration of the Diagnostic and Statistical Manual also eliminated the NOS designation, not otherwise specified as a choice that clinicians could make. From a theoretical standpoint, DSM-5 moved away from the categorical approach to nomenclature and adopted a dimensional approach. What that means is that instead of there being discrete diagnostic categories, the dimensional approach envisions many nodes along a line so that there are many more diagnostic possibilities. There are more shades of gray, if you will. And finally, DSM-5 envisions that clinicians will adopt a cultural formulation as part of their diagnostic assessments. DSM-5 ushered in some specific changes to the Substance Use Disorders Diagnostic Criteria. Those familiar once again with previous iterations of the Diagnostic and Statistical Manual will clearly remember that there were two broad categories called Substance Abuse and Substance Dependence. Those two broad categories were eliminated in DSM-5. We now have 11 criteria that are used for diagnostic purposes for substance-related disorders. Again, those of you familiar with previous iterations of the Diagnostic and Statistical Manual will remember that recurrent legal issues were one of the criteria that were used to diagnose substance use disorders. But that particular criteria was eliminated in DSM-5. Added to the 11 criteria was craving or a strong urge to use. DSM-5 recognizes two broad categories of substance use disorders, referred to as substance use disorders and substance-induced disorders. Each disorder in DSM-5 is additionally measured on a continuum from mild to severe, which again is a reflection of the elimination of the abuse and dependent diagnoses that were in the previous iterations of the Diagnostic and Statistical Manuals. This represents the shift to a dimensional approach that was adopted broadly in the DSM-5. And again, for the first time, we have a behavioral disorder that is added to the broad group of substance use disorders so that we now have diagnostic criteria for a gambling disorder. So what is a substance use disorder? That may seem an odd question to ask, but for purposes of this presentation, we need to make clear what this definition is since it will be the grounding point for all further assessments. So we need to look no further than DSM-5 for the answer to that question. So what is a substance use disorder? According to DSM-5, it's a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of 11 criteria occurring in the preceding 12-month period. So there are a couple of key elements here that you want to keep in mind. You must have at least two of the 11 criteria to meet the diagnostic definition, and it must be over a 12-month period. Making a diagnosis of a substance use disorder requires a comprehensive assessment, and DSM-5 recommends that clinicians consider five broad areas upon which they will base their assessment. You need to consider any changes in frequency and or dose of substance use. You want to consider the individual's own self-report. You're taking a clinical history and gathering information from them. It's also important, wherever it's possible, to get collateral data, report of knowledgeable others, meaning friends, coworkers, intimate partners. And of course, there are your observations, the clinician's observations. What do you see during your physical examination of the patient? And finally, DSM-5 introduces and underlines the importance of biological testing. As clinicians, we're fortunate that we have a wide array of biological tests that we can look to to help inform us about an individual's potential substance use disorder diagnosis, and we'll cover that in a bit more detail later in this presentation. So as painful as it might be, let's take the time to explore in detail the 11 criteria that are required for a substance use disorder as defined by DSM-5. You'll notice in the upper corner of this particular slide we have the number 11 circled in red. Keep this number in mind. It's an important number for the diagnosis of substance use disorders. So let's begin with the first. The substance is often taken in larger amounts over a longer period of time than was intended. Does this apply to your patient? Were there persistent efforts to cut down or control substance use? Did the individual try to only drink at certain hours of the day, or perhaps only after work, or perhaps only on the weekends? Is your patient spending a great deal of time trying to obtain the substance, using the substance, or recovering from its effects? Perhaps the individual had a significant hangover and was unable to get to work. And finally, can you ascertain whether or not the individual has a craving or strong desire to use the substance? And of course, this is manifested in many ways, as the individual finds it very difficult to go without their particular substance of choice for any particular period of time. You will also want to determine as part of your assessment whether or not the individual is failing to fulfill major role obligations at work, school, or home as a result of the recurrent use of a particular substance. Do they continue to use the substance despite having persistent or recurrent social or interpersonal problems? Now we can imagine that there might be arguments between intimate partners about one's use of a substance that's interfering in that relationship that might lead to arguments or even more serious repercussions or ruptures in that particular relationship. And does the individual have important social, occupational, or recreational activities given up or reduced because of substance use? Perhaps the individual at one time was engaged in attending a club or a meeting and as a result of the time spent using or acquiring their particular substance, they no longer have the time or the motivation to continue. These two criteria are particularly important. Does your patient continue to use their substance in situations in which it is physically hazardous? For example, driving an automobile under the influence of a substance would be a common situation that would meet this particular diagnostic criteria. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by that substance. This particular criteria can apply to a wide range of emotional and physical problems. For example, an individual may find it very difficult to get a good night's sleep, but in spite of knowing that alcohol is actually worsening their night's sleep, they continue to use it in the vain hope that they can recapture its now fleeting sedative effects. The same may also apply to an individual with post-traumatic stress disorder. PTSD may perhaps at one time have benefited from the sedative effects conferred by a substance such as alcohol. But again, that's a transient effect. And alcohol will actually worsen the night's sleep, increase the individual's anxiety, and have other unintended consequences that an individual may continue to accept in pursuit of their particular substance. The tenth criteria for a substance use disorder is the presence of tolerance. Tolerance in your patient would be defined by either of the two following situations. Does your patient have a markedly increased need in terms of the amounts of the substance to achieve the intoxication or desired effect? Or is there a markedly diminished effect with continued use of the same amount of the substance? If either or perhaps both of those conditions apply, then your patient has met the diagnostic definition of tolerance. The eleventh and final criteria for a substance use disorder is the presence of withdrawal. DSM-5 defines withdrawal as your patient manifesting either of the following. They have the characteristic withdrawal syndrome for the particular substance that they've been using, or, and it can be an and or, use of the substance or a closely related substance is taken to relieve or avoid the withdrawal symptoms. Another way to remember the eleven criteria that are used to diagnose a substance use disorder is to remember that they're grouped in terms of their content or their domains. So criteria one to four have to do with impaired control over the use of the substance. Questions five to seven have to do with social impairment that is caused by the recurrent use of the substance. Criteria eight and nine involve continued use of the substance in situations where it's hazardous, so that's risky use. And finally, DSM-5 includes criteria 10 and 11, which are both pharmacological criteria, which are used in the diagnosis of substance use disorders. So taken together, once again, we have the number 11. DSM-5 has one important caveat in terms of the pharmacologic criteria that clinicians must pay attention to when diagnosing a substance use disorder. And here it is on the slide. Those criteria 10 and 11, which include withdrawal occurring during appropriate medical treatment with prescribed medications, are specifically not counted when diagnosing a substance use disorder. In further quoting, the appearance of normal expected pharmacologic tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of addiction even when these were the only symptoms present. So it's an important caveat that DSM-5 specifically draws your attention to. But even that caveat has an important diagnostic footnote. However, prescription medications, as we all know, can be used inappropriately, and substance use disorder can be correctly diagnosed when there are other symptoms of compulsive drug-seeking behavior. As mentioned at the beginning of this presentation, DSM-5 eliminated the abuse and dependence diagnostic categories. In its place, DSM-5 now requires clinicians indicate the severity of the substance use disorder. And this particular slide shows you how to do that. If the individual meets two or three, remember you must have at least two of how many criteria? There are 11 criteria. So to meet the diagnostic criteria for a mild substance use disorder, the individual must have met two or three of those 11 criteria. If the individual met four or five of the criteria, they have a moderate substance use disorder. And finally, if the individual, in your broad assessment, met six or more of those diagnostic criteria, remember 11, if they met six or more of those 11, then they have a severe substance use disorder. A complete DSM-5 substance use disorder diagnosis also requires a longitudinal assessment of your patient's condition. If there have been no symptoms for greater than three months, but less than 12 months, you would indicate that the individual's substance use disorder is in early remission. If the individual has had no symptoms for 12 months, except for cravings, then you will indicate that your patient's substance use disorder is in sustained remission. And you also want to indicate if the individual's lack of access to substances accounts for their symptom remission. So perhaps being in a hospital environment or in a correctional setting, if their use of substances is curtailed, then you will indicate that by appending to your diagnosis in a controlled environment. Not every substance gets its own discrete diagnostic label, but those listed on this slide do. Alcohol, caffeine, cannabis, hallucinogens, and inhalants. And to that list, add opioids, sedative hypnotic or anxiolytics, stimulants, tobacco, and other or unknown, which is where you can list the specific substance that an individual meets diagnostic criteria for by listing this category. So DSM-5 added a new non-substance-related disorder, and this is now the gambling disorder. This is the only behavioral-based disorder listed in the substance-related and addictive disorder chapter. And now remember, there are 11 criteria for substance use disorders, but this non-substance-related disorder has only nine specific criteria. So we're now leaving DSM-5 behind and moving towards a focused practical discussion using the acronym SBIRT. SBIRT stands for Screening, Brief Intervention, and Referral for Treatment. It's an evidence-based approach to doing just what SBIRT stands for. This specific sub-module on SBIRT, again, standing for Screening, Brief Intervention, and Referral for Treatment, will introduce you to the basic concepts of SBIRT. You will learn how to conduct a screening, deliver a brief intervention, and we will very lightly touch on motivational interviewing. The American Osteopathic Academy of Addiction Medicine has another full presentation on this, and I certainly invite you to review motivational interviewing, as it's a foundation of addiction medicine. So, as always, let's begin with the definition of some of the key terms that you will need to understand as you begin to use SBIRT. First, screening involves a very brief set of questions that identify the risk of substance use-related problems. Screening should employ evidence-based tools. A brief intervention is a brief counseling session that raises awareness of the risks of substance use and will help motivate your client towards an acknowledgement of the problem. Brief treatment, this is cognitive behavioral work with your patients who acknowledge the risks of their substance use and have moved on and are seeking help, and referral, of course, are the procedures to help your patients access specialized care. At this point, you may be wondering, well, what are the benefits of SBIRT? How is this going to help my practice of addiction medicine? Well, very simply, it offers you a systematic approach to addressing substance use through the use of evidence-based techniques. In terms of SBIRT, screening is used to identify patients that are at risk. Important point here, patients at risk for substance use problems. In an ideal setting, SBIRT would like to help you identify patients in a preventive sense before they've progressed along the continuum of substance use disorders and have suffered more of the consequences of it. Now, there are many different ways clinicians can conduct screenings. What follows is a suggested approach. It's not a dynamic, one-size-fits-all approach. With that in mind, let's look at the type of screening tools that we could use in SBIRT. So we have self-report screening tools that are based on self-administered short questionnaires that are, of course, evidence-based. And of course, your interview itself, your clinical history, is another very important self-report. And then we have biological markers, such as breathalyzer tests, which are And then we have biological markers, such as breathalyzer testing, blood alcohol levels. We have indirect markers and serum drug testing. And we'll talk about those in more detail in subsequent slides. This slide identifies a selection of evidence-based screening tools. It is by no means comprehensive, nor is it intended to be. But what it does offer are some areas you should consider when selecting any particular screening tool. Of course, you want it evidence-based, which means that there's been published literature validating that particular tool that you're going to be using. But the screening tool should look at a particular substance, such as alcohol or more broadly, drugs. Can the tool be given to adults? Can it be given to adolescents, for example? And how is the tool administered? Is it self-administered or is it clinician-administered? This particular slide shows you the Audit C. Only three questions here. Please circle the answer that is correct for you, so your patient will circle. How often do you have a drink containing alcohol? How many drinks containing alcohol do you have on a typical day when you are drinking, and how often do you have six or more drinks on one occasion? So the Audit C is very simple. It doesn't take long. And the maximum score as is illustrated on the slide is 12, and a score of greater than or equal to four identifies 86% of men who report drinking above recommended levels, in other words, they're at-risk drinkers. A score of greater than two identifies 84% of women who are considered by this instrument to be at-risk drinkers. One of the most widely used, researched, and certainly recognized screening tools is the Audit, the Alcohol Use Disorders Identification Test. The Audit is a 10-question alcohol use screening instrument, and it's designed for primary healthcare workers. Although it may not be immediately obvious when casually using the Audit, but the 10 questions are divided into three categories, hazardous use of alcohol, dependence symptoms, and questions related to the consequences of alcohol use. On this slide, we see the first three questions are directed to men who On this slide, we see the first three questions are directed to hazardous alcohol use, so the first question is talking about the frequency of drinking, the second, the typical quantity that your patient is using, and the third question, the frequency of heavy drinking. The next three questions on the Audit involve symptoms related to dependence. So question four is asking your patient about their impaired control over their drinking. Question five is addressing their failure to meet expectations in their life, social, occupational, for example, because of their drinking. And question six is specifically asking about morning drinking. The last four questions on the Audit involve the harmful consequences of alcohol use. As your patient is filling out their own self-report, question seven will ask them whether or not they've ever felt guilty after drinking. Question eight will ask if they've experienced blackouts. Question nine is asking your patient whether or not they've had alcohol use Question nine is asking your patient whether or not they've had alcohol-related injuries. And finally, the last question, have other individuals expressed concerns about drinking? On this slide, we see the entire instrument in its entirety, the Alcohol Use Disorders Identification Test, otherwise known as the Audit. All 10 questions. So as the patient prepares to take this, they will see that they have five choices in terms of how they answer each question. For example, on question one, how often do you have a drink containing alcohol? As your patient contemplates the answer, they can choose between never, monthly or less, two to four times a month, two to three times a month, or four or more times a week. This pattern continues until we get to question number nine. Have you or someone else been injured as a result of your drinking? Here, the individual can choose between three options. They can say no, yes, but not in the last year, or yes, during the last year. And a similar pattern of responses also is seen in question number 10. Now, down to the bottom, you'll see that the patient is further instructed that in determining their response categories, it's been assumed that one drink contains 10 grams of alcohol. In countries where the alcohol content of a standard drink differs by more than 25 percent from 10 grams, the response category should be modified accordingly. This may or may not be present on the particular instrument you're using, but you should keep this in mind in terms of alcohol consumption patterns in your particular community. So your patient has completed the audit and you're now looking at the results. So how do you interpret your patient's responses? Well, this slide gives you a handy tool for doing just that. So if your patient scores 0 to 7 after you've tabulated the results, their level of at-risk hazardous drinking is considered low, and you as a clinician should simply provide encouragement. You can reflect back to them that they're in a low-risk category, and they should continue adopting the same level of consumption. However, if they score from 8 to 15, they're now considered low to moderate at risk in terms of their hazardous consumption of alcohol. And it's at this point you want to conduct a brief intervention, which we'll get to in a few slides more. If they score 16 to 19, they're at a moderate risk of hazardous drinking. Here, you want to consider both a brief intervention or you might want to consider a referral for treatment. And finally, if they're scoring 20 or above, they are considered a high risk and brief cognitive therapy or referral to treatment would probably be indicated. The Opioid Risk Tool, like the audit, is used to screen for at-risk use of opioids. This particular instrument can be filled out by the clinician, by you, if you have sufficient information to do so, or it can be filled out by your patients. Very simple, only five questions. They simply answer the questions, and then you tabulate the number of responses and come up with a score. For example, if your patient has a family history of substance abuse that involves prescription drugs, if they have a personal history of substance abuse, if they're between the ages of 16 and 45, if they have a history of preadolescent sexual abuse, and if they have depression, and if they're a female, then you would be scoring this as a four, plus a five, plus one, plus three, plus one, total score 14. So for this particular individual, they would be considered at a high risk of opioid misuse. So you see the scoring on the right, zero to three is low risk, four to seven moderate, greater than or equal to eight is considered high risk. Again, it's a very simple tool. It's not meant to replace any that you may already be familiar with that are evidence based tools, but it's simply a suggestion that you could adopt. Another simple, self-administered instrument that you can use in your clinical practice is the Drug Abuse Screening Test, otherwise known as the DAST-10. As the name implies, there are 10 simple questions that your patient will respond to. Reading from the slide, you see that the instrument refers to the past 12 months, which of course comports with the diagnostic criteria for a substance use disorder. So simple questions, have you ever used drugs other than those required for medical reasons? Are you unable to stop using drugs when you want to? Do you ever feel bad or guilty about your drug use? Have you ever experienced withdrawal symptoms, feeling sick when you stop taking the drugs? Simple yes, no responses are required from your patients. You will, of course, have the scoring sheet separate, but if they score zero, there are no problems, of course. If they score one to two, then the degree of drug problems related to drug abuse, in other words, they're at risk level, is considered low, and you would simply monitor the situation. If they score three to five, that's considered a moderate risk level, and you would want to probe more deeply, gather more information. And if they score six to eight, that's considered a substantial risk level, and you would want to conduct a much more intensive assessment that would probably include requesting contacts with friends, family, co-workers, for example, in the use of biochemical testing. So let's start pulling all the information that we've learned so far into a practical approach to screen for alcohol and drug use disorders among your patients. Now, again, I want to emphasize that this is simply a suggested clinical approach. You can adopt and amend this as it suits your particular situation so that flexibility is the key to patient-centered care. Now, as always, we need to start with some definitions. So before we launch into the suggested clinical approach to screening for alcohol use disorders, we need to define a standard drink. So 12 ounces of beer, which is about 5% alcohol, equals about eight to nine ounces of malt liquor, which is about 7% alcohol, which equals about five ounces of a typical table wine, which is normally about 12% alcohol. One beer is equal to about three to four ounces of fortified wine, such as sherry, which are about 17% alcohol. One beer would equal two to three ounces of a cordial liqueur or aperitif, which typically are about 24% alcohol. One beer, one glass of wine equals about 1.5 ounces of brandy, which also is sometimes referred to as a single jigger or shot, which is 40% alcohol. And finally, one standard beer, one standard glass of wine, one jigger of brandy equals about 1.5 fluid ounces of an 80 proof spirits, otherwise sometimes referred to as hard liquor, which is typically 40% alcohol. Now, another way to do this is to determine the number of fluid ounces of beer that the number of fluid ounces in a particular beverage, and then multiply that by the alcohol content. Using this particular formula, you would take, for example, 12 fluid ounces of beer times the alcohol content, which is 5%. That gives you 60 alcohol equivalents. Five ounces of wine times its 12% also equals 60 alcohol equivalents. So it's a quick, rough way to determine the standard drink contents that your patients are reporting. Now that we've determined what a standard drink constitutes, we can use this formula to determine at-risk drinking based on the amount of alcohol your patients are consuming. This is based on the National Institute of Alcohol and Alcoholism, so it's an evidence-based calculation. So among men, at-risk alcohol use is greater than four standard drinks per occasion. For research purposes, per occasion or per setting, if you will, is typically considered to be over a two-hour period. Among men, consuming greater than 14 standard drinks per week is considered at-risk alcohol use. Among women, greater than three drinks per setting or more than seven per week. And among older adults, those individuals 65 and older, per occasion greater than one or per week greater than seven. So to summarize, at-risk alcohol use among men greater than four and 14, women greater than three and greater than seven, and older adults greater than one and greater than seven. Easily memorized and applied in clinical practice. So now that we have the definition of a standard drink in place, and we now know the number of standard drinks will put an individual in an at-risk category, we can begin our suggested alcohol screening. And this is an example. So your patient is sitting in front of you. You simply ask two questions. How many times in the past year have you had more than four, if it's a man, or more than three, if it's a woman, drinks in a day. Your second question, how many drinks do you have in a typical week? A positive screen would be any number on question one. And on question two, if they've had more than 14 drinks in a week for men, or more than seven in a week for women. Suggested drug use screening is even simpler. You simply ask one question of your patient. How many times in the past year have you used an illegal drug, or used a prescription medication for non-medical reasons? A positive screen during your clinical evaluation would be if they answer one or more. If your patient was positive on the alcohol or drug screen, or both, your next step is to ask the patient to complete the audit, the DAST, or both, as the clinical situation dictates. So let's briefly review what we're doing up to this point. So your patient's sitting in front of you. And you ask two alcohol pre-screening questions. If they have a positive response, then you administer the audit. In a similar manner, you're asking one drug pre-screening question. And if that's positive, then you administer the DAST. So what do you do next? This slide pulls it all together. And provides suggested clinical interventions. So if your patient scores an eight to 15 on the audit, or a DAST of one to two, or both, they're considered at risk. And this would prompt a brief intervention from you. If, on the other hand, your patient scores a 16 to 19 on the audit, and or a three to five on the DAST, that's considered a moderate risk for alcohol and or drug use. Which in turn would suggest that you consider a brief intervention and or a referral to treatment. And finally, if your patient scores 20 or above on the audit and or six to eight on the DAST, they are considered at high risk for alcohol and or drugs. And this should be a consideration for a referral to treatment. So at various points in our discussion of SBIRT, screening, brief interventions, and referral to treatment, we have referred to brief interventions. So let's take a few minutes and talk about brief interventions for patients at risk for substance use problems. So at this point, you're probably asking, what are brief interventions? So here's a good definition. Brief interventions are brief opportunistic interventions that are short, face-to-face conversations with your patient regarding their drinking, their motivation to change, and the options for change, which are provided during a window of opportunity or a potentially teachable moment occasioned by a medical event. That medical event could be a presentation in an emergency room after an alcohol-related injury, as an example. Please remember that SBIRT is an evidence-based clinical program. With that in mind, brief interventions can trigger change. And there's a good body of clinical evidence that suggests this is the case, certainly when it comes to an alcoholic use disorder. So you may be wondering also at this point, what is a brief intervention in terms of the time it takes? And so research has demonstrated that a little counseling, as little as five minutes, can have the same impact as 20 minutes. Again, it's much to do with timing, particularly in relation to a medical event where the individual may be more receptive to change. Now, research is less extensive for brief interventions in terms of their impact when it comes to the use of illicit drugs, but there are promising studies. For example, on the slide here, we see that a randomized study with cocaine and heroin users found that patients who received a brief intervention had 50% greater odds of being abstinent at follow-up. As compared with controls. Given that it's a five-minute investment of your clinical time, it certainly seems worth it. Referral for treatment is always a clinical decision. It should be based on your experience in treating these particular conditions. And of course, the patient's interest. As a guide, approximately 5% of patients screened in a primary practice setting will require eventual referral for substance use evaluation and treatment. Some further guidance. A patient may be appropriate for referral when assessment of the patient's responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their continued substance use. But again, referral to treatment is always tailored based on your clinical experience and your patient's preferences. A comprehensive assessment of a potential substance use disorder relies on several sources of information. You have your clinical history. You may have access to others in the individual's environment, such as coworkers. You should have self-assessment instruments available for review. And finally, we're going to talk about laboratory testing, which is not confirmatory by itself. But when integrated with the other sources of information, can help inform a comprehensive assessment of a potential substance use disorder. Let's begin our discussion of alcohol and drug biochemical testing with a brief review of the means by which alcohol is eliminated from a person's body. This is important because all biochemical testing for alcohol relies on these methods. So the kidney eliminates approximately 5% of alcohol and or its metabolites in the urine. The lungs exhale 5% of alcohol, which forms the basis for breath testing devices. We'll not be talking about those, but again, this is the means by which breath testing devices are utilized. And finally, of course, the liver chemically breaks down the remaining alcohol in its final form into acetic acid. Alcohol biomarkers can be broadly grouped into two types, the indirect alcohol biomarkers and the direct alcohol biomarkers. Indirect alcohol biomarkers are measuring the impact of alcohol on body systems, which is why they're considered indirect. So this particular slide shows you a biomarker type, the type of drinking necessary to elevate that particular biomarker, that particular biomarker sensitivity and specificity, and what are some of the false positives. So for example, AST and ALT are common biomarkers for alcohol use. The amount of alcohol it takes to elevate AST and ALT is unknown, it's not precisely quantified, but it must be heavy and it must last for several weeks. Both AST and ALT are considered moderate in terms of sensitivity and specificity, lower than another that we'll be talking about in a minute, which is GGT. Sources of false positive can be such as excessive coffee consumption, which can lower those values. Now, another commonly used biomarker is the mean corpuscular volume, MCV. The amount of drinking necessary to elevate the MCV also is unknown, but it probably needs to be heavy and it must last for a few months. MCV's sensitivity is low, although it may have a moderate to high specificity. There are many sources of false positives for MCV, such as obviously liver disease, hemolysis, bleeding disorders, anemia, folate deficiency, and any medications that reduce folate. The indirect alcohol biomarkers listed on this slide are more precise in terms of screening. Carbohydrate-deficient transferin, commonly referred to as CDT%, will become elevated with at least five drinks per day for two weeks. Its sensitivity and specificity is moderate to high, but it may be elevated to a high level of moderate to high. There are false positives associated with CDT%. Iron deficiency can certainly affect it. The hormonal status in women. Carbohydrate-deficient, glycoprotein syndrome, hepatitis C, and severe alcohol disease. The other indirect alcohol biomarker that has a greater specificity and sensitivity is gamma-glutamyl transferase, otherwise known as GGT. And again, the amount of alcohol consumed has been quantified at five drinks per day for several weeks that's necessary to raise GGT. There are false positives for GGT. Liver and biliary disease, of course. Heavy smoking and obesity. Medications that induce microsomal enzymes. And GGT should be reported in terms of gender of its values. So you'll need to take that into account when assessing elevations of GGT. Ethyl glucuronide, ETG, and ethyl sulfate, ETS, are direct alcohol biomarkers. They are minor metabolites of alcohol. Typically, ETG and ETS are assessed in urine samples. ETG, ethyl glucuronide, can be detected with as little as a single drink. And with a window of detection up to 80 hours, it can be a very useful test. Its sensitivity is high, specificity unknown. Ethyl sulfate has a similar type of drinking pattern, just perhaps a single drink, high sensitivity. Because they are both metabolites of alcohol, false positives would naturally come from any consumption of alcohol, such as in medications. But laboratories that do ETG and ETS testing set levels for what they consider a positive test that takes into account the incidental or accidental consumption of alcohol. Drug testing is complicated. And drug testing in the workplace is even more complicated and fraught with regulatory and regulatory barriers. And fraught with regulatory and legal hurdles that need to be understood, but are well beyond the scope of this presentation. This slide is simply offered as a way to demonstrate how drug testing works. In the workforce, the typical process involves the two-step mechanism. Urine samples are subjected to an immunoassay of some sort. These are sensitive, inexpensive, but good enough to detect levels of the substance at specific levels. So let's, for example, focus on cocaine. The initial test from an immunoassay must be at least 150 nanograms per milliliter before that would be considered a positive screening test result. As you see, if you follow the table over, it is a metabolite of cocaine that is actually tested for. That is the analyte. Cocaine is just metabolized far too quickly to be detected. If an individual on a screening immunoassay test scores 150 nanograms per milliliter or greater, drug testing in the workplace would typically require that sample undergo a confirmation test involving sophisticated equipment such as mass spectrometry, which would identify the specific chemical signature. And if that level came at 100 nanograms per milliliter or greater, that would be considered a confirmed test for the presence of that cocaine metabolite in the urine. So as you can see, looking at this slide, drug testing is complicated and, in fact, requires a good deal of training to be done. In a manner that will withstand scrutiny. Now, when it comes to drug testing, certain terms need to be defined. The term opiate specifically refers to the natural alkaloids extracted from the opium poppy. The term opioid refers to synthetic opiates and opiate-like drugs in addition to the naturally occurring opiates. As a clinician, it's important to remember that synthetic or semi-synthetic narcotics do not metabolize to codeine, morphine, or 6-acetylmorphine, which would be found in heroin. These include but are not limited to the long list of analgesics on this slide. So what is the importance of understanding this? What it means is that each of the analgesics listed here must be tested for individually. If your urine drug test does not specifically state that it checks for oxymorphone or hydrocodone, then it will not be reported. As a rough rule, when it comes to opiates and drug testing, a urine can detect and will remain positive for two to four days after consumption. In terms of marijuana drug testing, it boils down to frequency of use. A marijuana can be positive in as little as one day when it comes to infrequent use or up to three weeks if the individual is a habitual user of marijuana. Using current cutoff values, an infrequent user will test positive for marijuana for only about three days. Again, these are rough guidelines. When it comes to cocaine, as I previously mentioned, drug testing cannot detect the cocaine itself. It's too rapidly metabolized. But the first pass metabolite of cocaine can be detected and remain positive in urine for up to two to four days. Of course, encyclodine has no medical use at the present time, but even casual use can be detected. But even casual use of PCP can result in a positive urine as far out as two to four weeks. So we've come to the end of this presentation, and let's take just a minute to review what we covered. We spent a little bit of time talking about DSM-5 with particular emphasis placed on the substantive changes that were put in place affecting the diagnoses involving substance use disorders. We did a brief introduction to SBIRT. And as you remember, that is Screening, Brief Intervention, and Referral to Treatment. We next looked at some screening assessments, some specific tools. These were just suggestions that could be used in your screening for alcohol use disorders and drugs. And finally, we did a stratospheric overview of laboratory assessments and how the use of biomarkers for both alcohol and drugs could be used as part of a comprehensive assessment to help inform your clinical assessment of a potential substance use disorder. In closing, I'd like to thank you for your attention, and I hope you found this introduction to the assessment of substance use disorders useful. And please take a look at the other slide sets that we have covering a variety of different topics. Again, thank you for your attention.

Substance Use Disorders

DSM-5

SBIRT

Addiction Medicine

Screening Tools

Brief Intervention

Cultural Formulation

Biochemical Testing

Patient Assessment

American Osteopathic Academy