Key Areas of Assessment
- ✅ Type of Substance: Alcohol, opioids, stimulants, cannabis, hallucinogens, benzodiazepines, etc.
💡 Knowing the specific substance helps tailor interventions and understand the risk profile and potential health complications. -
✅ Frequency & Amount: Daily, weekly, occasional use; quantity per use session.
💡 Frequency and amount indicate the severity of use, risk of dependence, and potential impact on health and daily functioning. - ✅ Route of Administration: Oral, smoking, injection, snorting, transdermal.
💡 The route affects absorption speed, overdose risk, and potential for infections or tissue damage. -
✅ Duration of Use: Recent onset vs. long-term use history.
💡 Duration provides insight into chronicity, dependence patterns, and associated long-term health risks. -
✅ Tolerance & Dependence: Increased quantity needed, withdrawal symptoms.
💡 Tolerance and dependence indicate physiological adaptation and potential for severe withdrawal, guiding treatment urgency. -
✅ Cravings & Triggers: Emotional, environmental, social influences.
💡 Identifying cravings and triggers aids in developing targeted behavioral interventions and relapse prevention strategies. -
✅ Periods of Abstinence & Relapse History: Length of sobriety, relapse patterns.
💡 Understanding past abstinence and relapse patterns informs prognosis and supports sustained recovery efforts. -
✅ Impact on Daily Life: Relationships, work, health, legal, financial consequences.
💡 Assessing the broader impact helps determine the need for comprehensive support and tailored intervention strategies. -
✅ Co-Use & Polydrug Use: Combining substances, interactions, overdose risk.
💡 Co-use increases treatment complexity and heightens the risk of adverse interactions and overdose. - ✅ Previous Treatment Attempts: Detox, rehab, harm reduction strategies.
💡 Past treatment efforts help guide current interventions and identify effective strategies for recovery.
Assessment Prompts & Questions
- “Can you tell me about your current substance use? What are you using, and how often?”
- “How has your substance use changed over time?”
- “Do you ever feel like you need to use more to get the same effect?”
- “Have you experienced any withdrawal symptoms when you stop using?”
- “Are there certain situations or emotions that lead you to use?”
- “Have you tried cutting down or stopping before? What happened?”
- “How does substance use impact your daily life, relationships, or work?”
- “Do you mix different substances? If so, which ones and how often?”
Risk Assessment & Harm Reduction Strategies
🚨 High-Risk Indicators:
- Signs of overdose risk (e.g., extreme drowsiness, slowed breathing, confusion).
- IV drug use without sterile equipment, increased risk of infections (HIV, Hep C).
- Dependence with severe withdrawal risks (alcohol, benzodiazepines, opioids).
- Blackouts, memory loss, severe intoxication episodes.
🛑 Harm Reduction Steps:
- Encourage safer use strategies (clean equipment, spacing out doses).
- Provide overdose prevention education and access to Naloxone.
- Support gradual reduction plans or detox referrals.
- Explore coping alternatives for cravings and triggers.
- Engage in multi-agency support (medical, mental health, social services).