Clinical Evaluation
Screening versus assessment
A screen (AUDIT, DAST-10, CAGE) flags risk; it never establishes a diagnosis. Diagnosis requires a comprehensive biopsychosocial assessment: presenting problem, history of use, withdrawal, medical and psychiatric status, family and social history, legal and employment issues, trauma, strengths, and culture. Use collateral sources only with a signed release.
DSM-5 and ASAM
DSM-5 substance use disorder uses 11 criteria across four groupings. Meeting 2–3 = mild, 4–5 = moderate, 6+ = severe. Specify remission (early, sustained) and controlled environment. ASAM's six dimensions guide level of care: (1) intoxication/withdrawal risk, (2) biomedical, (3) emotional/behavioral/cognitive, (4) readiness to change, (5) relapse potential, (6) recovery environment.
Traps
Questions often present a positive screen and ask for a diagnosis-assessment is still needed. Tolerance and withdrawal count as criteria; do not exclude them because a prescription was involved. Alcohol and benzodiazepine withdrawal can be life-threatening; opioid withdrawal is intensely unpleasant but rarely fatal. Distinguish intoxication from withdrawal.
Worked example
A client endorses tolerance, withdrawal, using more than intended, and repeated attempts to cut down = 4 criteria = moderate SUD. Because withdrawal is present, ASAM Dimension 1 requires medical monitoring; a medically monitored level may be indicated rather than outpatient alone.