---

History Taking in Substance Use

---

1. Approach and Setting

• Use open-ended questions first ("Tell me about your alcohol or drug use"), then narrow.
• Be alert to definitional misunderstandings - patients may say "I don't drink alcohol" but later mention daily beer, or underestimate quantity ("I water down my bourbon").
• Normalise the questions ("I ask all my patients these questions").
• A computer-based self-administered questionnaire may improve accuracy versus face-to-face screening alone.

---

2. History of Use (All Substances, Ever)

• Age of first use - earlier onset correlates with higher lifetime risk of disorder.
• Length and pattern of use - episodic, binge, daily, weekend-only.
• Date of most recent use.
• Route of administration - oral, smoked, snorted, intravenous.

---

3. Current Use (Quantity and Frequency)

• What substances are currently used?
• How much on a typical day/occasion?
• How often (daily, weekly, monthly)?
• Maximum quantity - "Do you ever drink/use more than usual? If so, how much?"

• Males <65 years: >/= 5 standard drinks/day or >14/week
• Females and males >/= 65 years: >/= 4 standard drinks/day or >7/week

---

4. Mode of Ingestion and Triggers

• How is the substance taken (ingest, smoke, snort, inject)?
• What triggers use? (stress, social situations, specific people or places, emotional states)
• How does it make you feel - what is the desired effect?

---

5. Features of Dependence

---

6. DSM-5 Substance Use Disorder Criteria

---

7. Negative Consequences

• Physical health - injuries, infections (HIV, hepatitis B/C from shared needles), organ damage (liver, cardiac), nutritional status.
• Mental health - depression, anxiety, psychosis, suicidality (comorbid psychiatric disorders are common; anxiety disorders ~60% and SUDs ~25% co-occur with major depression).
• Social - school or work problems, job loss, cessation of hobbies or activities.
• Family/relationships - arguments, domestic violence, child neglect.
• Legal - arrests, DWI, incarceration.

---

8. Risk Evaluation (Safety History)

• Have you ever injected drugs? If so, do you clean equipment? Do you share needles?
• Have you ever exchanged sex for drugs or money?
• Do you use alone? (risk of unwitnessed overdose)
• Have you ever overdosed? Have you witnessed someone else overdose?
• Do you have a naloxone kit? Do you know how to use it?

---

9. Social and Family Environment

• Substance use among family and/or peers?
• Family history of substance use disorder? (strong genetic component)
• Home environment - stable housing, supportive relationships?

---

10. Psychiatric Comorbidity

• Current and past psychiatric diagnoses and treatments.
• Suicidal ideation, intent, plan, and past attempts (SUD markedly elevates suicide risk).
• History of trauma or adverse childhood experiences.
• Psychotic symptoms (stimulants and cannabis can precipitate psychosis).

---

11. Treatment and Cessation History

• Have you ever tried to quit or cut down?
• Longest period of abstinence - what maintained it?
• What triggered relapse?
• Have you received formal treatment? (detox, residential, outpatient, support groups like AA/NA)
• Have you been on pharmacotherapy? (methadone, buprenorphine, naltrexone for OUD; acamprosate/disulfiram for alcohol)
• Current goals - abstinence, harm reduction, reduction in use?

---

12. Screening Instruments

CAGE Questionnaire (alcohol)

AUDIT (Alcohol Use Disorders Identification Test)

DAST-10 (Drug Abuse Screening Test)

RAPS4 (Rapid Alcohol Problem Screen)

ASI (Addiction Severity Index)

NIDA-Modified ASSIST

---

13. Strengths and Resources

• Family or community supports available?
• Coping skills already in place?
• Motivation and readiness for change (Prochaska's stages of change - pre-contemplation, contemplation, preparation, action, maintenance)?

---

Summary Framework (Mnemonic: CADRES-T)

---

• The Harriet Lane Handbook (Johns Hopkins), 23rd ed., p. 161 - Table 5.2
• Goldman-Cecil Medicine, International Edition, History section pp. 3586-3639
• Kaplan and Sadock's Synopsis of Psychiatry, pp. 264-270
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Substance Use Disorders
• Miller's Anesthesia, 10e - Patients with History of SUD, pp. 4007-4009
• Harrison's Principles of Internal Medicine, 22e - Mental Health and Addiction

---

One Standard Drink

US Definition

Equivalent Serving Sizes (US)

UK/International Definition

• 340 mL (12 oz) of beer
• 115 mL (4 oz) of non-fortified wine
• 43 mL (1.5 oz) shot of 80-proof spirits

Why It Matters Clinically

• A typical commercial serving is often larger than one standard drink (e.g., a restaurant pour of wine is usually 6-8 oz, not 5 oz).
• Quantifying alcohol in grams rather than "drinks" is more accurate because patients underestimate portion sizes.
• Risky use thresholds (where health consequences begin):
  • Men: >14 standard drinks/week or >2/day
  • Women: >7 standard drinks/week or >1/day
• High-risk thresholds (from the previous history on SUD): >/= 5 drinks/day for men <65 yrs, >/= 4 drinks/day for women or men >/= 65 yrs.

---

Motivational Interviewing (MI) for Substance Use Disorder

A Complete Presentation Guide with Real Case Scenario

---

SLIDE 1 - What is Motivational Interviewing?

• Developed by William Miller (1983) originally to treat alcoholism
• Not a bag of tricks - it is a way of being with patients
• Core philosophy: the motivation and desire for change must come from the patient, not the clinician
• The clinician's role is to draw out and strengthen that existing motivation

---

SLIDE 2 - The Core Spirit of MI (PACE)

---

SLIDE 3 - The RULE Principles (Clinical Application)

---

SLIDE 4 - Stages of Change (Prochaska & DiClemente, 1984)

Precontemplation → Contemplation → Preparation → Action → Maintenance
                                                                ↑
                                                            Relapse
                                                         (can occur at
                                                          any stage)

---

SLIDE 5 - Core MI Techniques: OARS

O - Open-Ended Questions

• Invite the patient to talk rather than give yes/no answers
• Examples:
  • "What concerns do you have about your alcohol use?"
  • "Tell me what a typical day looks like for you."
  • "How does your drug use fit into your life right now?"

A - Affirmations

• Acknowledge strengths, efforts, and what the patient is already doing well
• Not flattery - genuine recognition
• Examples:
  • "You've shown real courage by coming in today to talk about this."
  • "Even though things have been difficult, you haven't given up on yourself."
  • "You may not be at your goal yet, but look at how far you've come."

R - Reflective Listening

• Reflect back what the patient says to show understanding and invite deeper exploration
• Types of reflections:
  • Simple: "So you've been drinking more lately."
  • Complex/Amplified: "It sounds like the drinking helps you cope with stress, but part of you worries it's getting out of control."
  • Double-sided: "On one hand, alcohol helps you relax. On the other hand, you're worried about what it's doing to your liver."
• Examples:
  • "It sounds like you don't feel confident about making this change, but you do want to change."
  • "So the heroin helps you feel normal - like you can't function without it."

S - Summaries

• Periodically summarise what has been discussed - shows you are listening and creates momentum
• Examples:
  • "Let me make sure I've understood what you've shared with me today..."
  • "So you're using cocaine about three times a week, it started after your divorce, and you're worried about your job..."

---

SLIDE 6 - Key MI Techniques Beyond OARS

1. Developing Discrepancy

• Gently highlight the gap between the patient's current behaviour and their stated values/goals
• "You told me being a good father is the most important thing to you. How does your drinking fit with that?"
• "You want to be healthy enough to see your grandchildren grow up. What do you think your current drug use is doing to that goal?"

2. Rolling with Resistance

• Do NOT argue, confront, or correct - this increases resistance
• Resistance is a signal to change your approach, not to push harder
• Techniques:
  • Shift focus: "Maybe we don't need to talk about that right now."
  • Agree with a twist: "You're right - I can't force you to change."
  • Reframe: "It's actually a sign of how much stress you're under."

3. Eliciting Change Talk (DARN-C)

4. Importance and Confidence Rulers

• "On a scale of 0 to 10, how important is it for you to change your drug use?"
• "On the same scale, how confident are you that you could change if you decided to?"

• "You said 6 for importance. Why not a 3?" (draws out their own reasons for change)
• "What would it take to move from a 4 to a 7 in confidence?"

5. Exploring Ambivalence

• Asking about the pros and cons of use AND the pros and cons of change
• "What do you like about using heroin? What are the not-so-good things?"
• "What would be the good things about cutting back? What worries you about stopping?"

6. Enhancing Self-Efficacy

• Patients with SUD often believe they cannot change - address this directly
• Reference past successes: "You've cut down before - what helped you do that?"
• Use statements like: "Many people with much more severe use have made this change."
• "I believe you have what it takes to do this."

---

SLIDE 7 - MI Strategies by Stage of Change

---

SLIDE 8 - What NOT to Do (Common Pitfalls)

---

SLIDE 9 - REAL CASE SCENARIO

"Ahmed" - 34-year-old male with Alcohol Use Disorder

---

Full MI Consultation Transcript

---

---

SLIDE 10 - What Happened in That Consultation (Analysis)

---

SLIDE 11 - Evidence Base

• Dozens of randomised controlled trials show MI produces significant change in alcohol, tobacco, and substance use compared to control groups. (Miller et al., 2004)
• In a systematic review (Rubak et al., 2005) of 72 RCTs - 74% showed MI to be more effective than traditional advice alone.
• Meta-analyses confirm MI has moderate to strong effects on substance use, with benefits often equivalent to longer or more expensive treatments.
• MI has been validated across cultures, age groups, and settings (primary care, emergency department, inpatient, outpatient psychiatric).
• Evidence grade: SOR: A (Lundahl et al., 2010; Martins & McNeil, 2009; Rubak et al., 2005)

---

SLIDE 12 - Limitations of MI

• Efficacy is not consistent across all health problems - some areas have mixed results
• Assessment tools for MI fidelity are still being validated
• Many studies lack detail on intervention specifics, making reproducibility difficult
• Benefit depends heavily on clinician training quality - works best with 1:1 coaching and individual feedback
• MI alone is insufficient for severe SUD - pharmacotherapy (methadone, buprenorphine, naltrexone, acamprosate) and structured treatment are usually also required

---

SLIDE 13 - Summary: The MI Mindset in 5 Lines

1. Don't fix, guide. The patient is the expert on their own life.
2. Ambivalence is normal. Your job is to tip the balance, not eliminate resistance.
3. Change talk is gold. Listen for it, reflect it, amplify it.
4. Roll, don't push. Confrontation produces the opposite of change.
5. Autonomy is the engine. When patients choose change, they sustain it.

---

• Textbook of Family Medicine, 9e - Chapter 8: Health Behavior Change and MI
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Motivational Interviewing; Strategies by Stage of Change
• Kaplan and Sadock's Synopsis of Psychiatry - Techniques in Psychiatric Interviewing
• The Harriet Lane Handbook, 23rd ed. - Brief Interventions in Substance Use

---

The Transtheoretical Model (TTM) and Motivational Interviewing - A Complete Integration

---

The Core Relationship

• TTM (Prochaska & DiClemente, 1984) is a diagnostic map - it tells you where the patient currently stands in their readiness to change
• MI (Miller & Rollnick, 1983) is a therapeutic toolkit - it tells you what to do at each location on that map

"For some types of addictions, the therapeutic alliance improves when the treatment approach is tailored to the patient's stage of readiness to change."

• Kaplan and Sadock's Synopsis of Psychiatry

---

The TTM Stages: Definitions

---

Stage-by-Stage Integration with MI

---

STAGE 1 - Precontemplation

---

STAGE 2 - Contemplation

---

STAGE 3 - Preparation

---

STAGE 4 - Action

---

STAGE 5 - Maintenance

---

STAGE 6 - Relapse

---

The Integrated Visual Model

                         ┌─────────────────────────────────┐
                         │      TRANSTHEORETICAL MODEL      │
                         │         (Where they are)         │
                         └─────────────────────────────────┘
                                         │
              ┌──────────────────────────┼──────────────────────────┐
              │                          │                          │
     PRECONTEMPLATION           CONTEMPLATION               PREPARATION
     MI Goal: Raise doubt       MI Goal: Resolve             MI Goal: Build plan
     Tools: Open Qs,            ambivalence                  Tools: Confidence ruler,
     ask permission,            Tools: Discrepancy,          explore options,
     give info neutrally,       importance ruler,            clarify goals,
     avoid righting reflex      double-sided reflection,     personal choice,
                                pros/cons exercise           anticipate barriers
                                          │
              ┌───────────────────────────┤
              │                          │
           ACTION                  MAINTENANCE
     MI Goal: Support              MI Goal: Prevent relapse
     & reinforce                   Tools: High-risk situations,
     Tools: Affirm progress,       relapse plan,
     problem-solve,                build new identity,
     reinforce self-efficacy       address complacency
              │
              └─────────────────────────────────────────► RELAPSE
                                                    (Re-enter cycle; MI: 
                                                     non-judgment, explore
                                                     trigger, rebuild
                                                     self-efficacy)

---

Why the Integration Works - Key Principles

1. MI is built on the TTM premise - that each patient holds intrinsic motivation for change, and the clinician's role is to elicit and strengthen it at the patient's current stage.
2. Mismatch is harmful - Using Action-stage strategies (making plans, prescribing treatment) on a Precontemplation-stage patient creates resistance and damages the alliance. Matching stage to MI strategy prevents this.
3. The cycle is normal - Relapse is explicitly accounted for in TTM and MI teaches clinicians to respond to it with compassion, not judgment - which is what brings patients back.
4. Ambivalence is the pivot point - TTM says Contemplation is the stage of ambivalence; MI's central mechanism is resolving ambivalence. The two models align most powerfully at this stage.
5. Self-efficacy bridges Preparation to Action - Both models identify low self-efficacy as the key barrier between intending to change and actually changing. The confidence ruler and affirmation strategies directly target this.

---

• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Strategies Using MI Based on Stage of Change (Table 27.4-8); Treatment of SUD in HIV patients
• Kaplan and Sadock's Synopsis of Psychiatry - Selecting a Treatment; Transtheoretical Model
• Textbook of Family Medicine, 9e - Chapter 8: Health Behavior Change and MI; Stages of Change Table 8-1; OARS Table 8-2
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Disturbances of Judgment; Stages of Readiness for Change