Episode 83

Taking a drug use history can sometimes feel like guessing. What questions should you ask? What do the answers mean? Did you ask the right things? In today’s episode we will be going over the questions I feel are necessary in getting a good history on someone’s substance use. There are of course more questions we could ask and there are other ways of doing this. My way is just one way of doing things. Ultimately, do this however you feel works best for you and is most natural for you. My main goal is to encourage therapists to include substance use conversations as part of their normal therapy conversations and assessment of someone’s functioning.


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 83.  Recently we’ve started talking about assessing substance use. We talked about setting up the conversation to minimize defensiveness and to increase rapport building with your client. We’ve talked about what goes into a substance use Assessment and how to look at things through a substance use lens. Today, we’re going to be talking about getting a substance use history. 

The way this differs from a substance use Assessment is that the history is just simply that; we want to find out what their history is like when it comes to their use of substances. This is the same way we would get a mental health history or a medical history. We’re not doing a full Assessment. You’re just adding this to the way you do intakes as another section to get the history on. 

If you choose to diagnose, this is where you would get the information about that and that’s not something you have to do. What I’m encouraging you to do is to get the information so that you know if there’s anything there and if it indicates that you need to ask more questions. Simply stated we’re getting the details of how much, how often and what the substance is.

On a typical chemical dependency Assessment there are about 10 to 15 substances that are included. That’s not necessarily something you need to do. Unless, people have used a lot of different substances. 

So when you start asking about substances, you start talking about alcohol and marijuana. Those are the main substances that people have experienced with alcohol first and then marijuana. Percentage-wise that’s what I usually see after alcohol and marijuana.

If those are both positive, then I ask about hallucinogens, acid, shrooms, ecstasy, things like that. If the answer is yes to any of those then I might ask about pills: over the counter prescription stimulant or depressant.  If that’s positive in the sense that they have used those things or tried them, then I might ask about further things.

So we can look to the DSM to see how they classify things. I don’t know if you’ve had a chance to look at your DSM  in the substance use disorder section. It’s in alphabetical order. Once we get past the basic substance use disorder description. The first one is alcohol use disorder. And in our move from DSM four to five, we moved away from abuse and dependence to mild, moderate, and severe.

I personally have never used the codes for intoxication or withdrawal. Those just aren’t things that I’m going to bother with because typically that’s not happening in my first assessment and my policy that I won’t do sessions with people when they’re intoxicated or under the influence. I find those to be more for acute medical settings.. 

I have used substance induced disorders on occasion during my career, when I have found substance related psychosis that only exists when they’re using or substance use related anxiety, that only happens while they’re using as well. 

After alcohol is caffeine. I find it interesting that they include it because there isn’t a caffeine use disorder. It’s caffeine intoxication, caffeine withdrawal, other caffeine induced disorders and unspecified caffeine related disorder. I find that sort of curious. 

I have seen people over the years who truly have some severe caffeine use disorder, even though that’s not a diagnosable condition. I once worked with someone who used to go to three or four gas stations a day to get their energy drinks, because they didn’t want the people to know how much they were using on a day-to-day basis. 

After caffeine, we get to Cannabis. Cannabis and Marijuana are becoming more synonymous. They are the same thing, but as we know from talking about CBD, Cannabis is also responsible for hemp. There’s different types of cannabis. Although they’re the same plant. One is marijuana and the other is for hemp. If you haven’t had a chance to listen to the CBD episodes, head on over to betsybyler.com and check those out.

The next section in the DSM is where things get a little bit different. Because the next section is hallucinogens specifically, it’s called hallucinogen related disorders. It differentiates between things that are PCP or Phencyclidine and other hallucinogens.  You can learn more about the different hallucinogens in the hallucinogen episodes on the website as well. 

PCP is probably the most dangerous of all the hallucinogens. Although ecstasy can be pretty dangerous as well, but PCP is the one that is typically known for aggression and some pretty intense behavior. I’m wondering if that’s why they decided to separate them. There’s PCP, or like I said, phencyclidine and then “other”. 

In the other hallucinogen category, we’re talking about things like ecstasy or MDMA, psilocybin or mushrooms, acid sometimes called LSD and DMT, which is becoming more popular.  Excluded from this group is cannabis, even though  there are hallucinogenic properties. It’s separated from hallucinogens because of significant differences in their psychological and behavioral effects. There are other hallucinogens that I didn’t name, of course. If you’re interested, go check out your DSM. The big DSM has a lot of really good information, diagnostically speaking. 

The section after hallucinogen is inhalant use. This is about huffing gasoline, air duster,  or any other number of aerosols. The next is opioid use disorder, which is going to include prescription pill opiates as well as heroin. After opioid use disorder comes sedative, hypnotic or anxiolytic related disorders. This category typically includes things like benzodiazepines and sleep medications.

Then we get to stimulant use disorders. Stimulant use disorders are going to include things like cocaine, crack methamphetamine, or other stimulants like that included in this section are things like methylphenidate, which is the generic name for one of the main ADHD medications that we use.  This section also includes the other type of ADHD medications, which is in the amphetamine class. This all falls under the stimulant use disorder category. 

Then we have tobacco use disorders followed by other or unknown substance use disorders. In this other or unknown category the other part refers to things like Benadryl or Imodium A D or nitrous oxide, and steroids. In the unknown part that would be if somebody was using pills that they didn’t know, but we’re getting them  and we’re exhibiting some dependence upon them. I think I’ve only diagnosed that once or twice in my career, but it is there as a catch all.

So we don’t ask about all of those substances. If somebody has used alcohol and marijuana, like I said, I’ll typically then ask about hallucinogens. If the answer is no, but they’ve used marijuana significantly, I might ask if they’ve ever tried using any pills. If the answer is no to that, then typically there isn’t a yes to be had.

I might say anything else that I didn’t mention, and maybe they’ll bring something up like they tried huffing once, but it’s typically not going to go farther than that. There is a progression when it comes to different substances that are used. Part of that is about availability, part of that is about perceived risk and it’s just sort of how people’s use progresses. They typically start with alcohol or marijuana. 

Now in some communities across the globe, inhalants are a really big deal, specifically glue. There are really cheap substances over the counter, like air duster and glue that can be extremely addictive, really dangerous by the way, cause some significant brain damage and are readily available and so a lot of youth will end up using them. There’s actually some significant and troubling use of inhalants by homeless youth in different countries.

Because you’ve set up the conversation in such a way that your client knows what you’re asking is ready for the questions and feels like they’re not being put on the spot. You’re starting with have they ever drank? When was the first time they ever drank and each time you get through one of those substances, you’re moving on to the next. So let’s talk about what you’re looking for when you’re asking about substances. 

The first thing I want to know is the first time. The reason I want to know this is that early use is highly correlated with problematic behavior later in life. Someone who first got drunk in high school is really different from someone who first got drunk at age eight.

I’ve done substance use histories and progression mapping with hundreds of clients over the years and the thing that I see that research also backs up is that early use really does highly correlate with problematic use later. The people that I have who are significantly deep in their addiction typically have started using really early. 

Now, when we’re talking about alcohol, we’re not talking about a sip from someone’s beer. We’re not talking about having a glass of wine with the family on a holiday. We’re talking about deliberately using in order to get intoxicated and having a drink to themselves 

I want to know how old. What I want to know about that first time is did they get drunk? Did they get sick? And then I want to know after that first time, when did they drink again? The typical pattern is that they didn’t drink for a while. Usually it could be a few months and in a lot of cases, it’s several years.

If it was really soon afterwards, That is telling and that’s sort of a flag to me that there may be some problematic use coming. After I established that I want to know when was there a time when they were using more than just experimenting? So, this is more than just once in a while when it’s around. This is sort of more actively planning to. 

So in high school, were they using every weekend? Was it both days during the weekend? Was it three or more days? If you get to a no, like, no, it was more like once or twice a month or no, it was only in the summer and then when the school year started, I wasn’t drinking. Okay. So those are the kinds of things that I’m looking for as a pattern. There is a progression of use whether or not it’s problematic use or not.

That starts with, well, no use of course, to experimentation, to misuse. Where somebody is misusing alcohol, meaning that they’re doing it to get drunk. That word misuse can sometimes seem moral. Like we’re casting a moral judgment on it when we’re not. We’re talking about deliberately using a substance to excess in order to make it do a certain thing.

I’ve already talked about in tons of episodes that this is really normal. In every culture. There is a way to use a substance to alter your state of mind.  So I want to find out the pattern and specifically I’m looking for, was there a period of time where their use of that substance, and right now we’re talking about alcohol, got a little out of hand. 

For some people they got out of hand in college for other people, maybe it was high school. Or perhaps it was getting a job where the thing was to go out for drinks after work and to try to close the bar or go out for happy hour or whatever it is. That’s what I’m looking for. Next I want to know about now. 

So simply stated first worst and last. And it’s not so much worse as in again, some sort of moral issue, but just trying to categorize it to help you remember it. I want to know the last time they used that substance and how often that’s happening now. 

Once I get through that with alcohol, I’m going to ask about marijuana. Then after I get through marijuana, if there was some significant use, meaning more than just a couple of times that they’re past the experimentation and into the more misused category that’s more significant.

And then I’m going to ask about things like hallucinogens because there are a lot of people who have used a hallucinogen maybe once or twice. Hallucinogens typically aren’t someone’s drug of choice although I’ve seen that, it’s just not as common for a lot of reasons.

After I ask about hallucinogens, I will likely ask about pills even if hallucinogens were a no, because pills are  more commonly abused especially in the last, say 10 to 15 years, we’ve been seeing a big rise. And part of that is just people feeling more lax about sharing medications with each other. It could have been that it was over the counter medication like Robitussin or the main active ingredient dextromethorphan. It could have been Adderall or some other kind of ADHD medication. It could have been a pain medication. It could be Benadryl who knows. And so I’ll just ask if they’ve ever tried using pills of any kind. 

When you get to the end of that, that’s kind of your substance use history. At this point, you can kind of tell whether you’ve gotten the gist of it or whether there might be a need for more questions.

Part of the history is just important for us. That can tell us a lot about what was happening in their life, how they were coping with it, whether there might be some events from that time period that are difficult for them. But primarily we want to know about substance use now.  Because substance use and problematic substance use specifically is going to impact therapy.

Last week, we talked about protecting the therapy hour. The reason for that is that one of the ways that substance use can impact our therapy sessions and progress in therapy is when somebody is coming, coming to the session under the influence or recovering from the effects of a substance. The other way though is about what’s happening in their brains. 

Using substances in a problematic way is going to have an impact on somebody’s current functioning and their ability to cope with problems and follow through on things. Knowing this information can be really helpful. 

In the episode last week, I talked about having  an EMDR processing session where I didn’t know that the client was high from marijuana. She didn’t look high, she didnt act high and I didn’t know but the EMDR processing session went off the rails pretty quickly. It was as though the traumatic memory that we were working on was increasing and somewhat changing and her distress was going up. So in that case, you want to pull the plug on that pretty quickly.

And that’s something that you need to know if somebody is showing up and they’re high, because if they’re high, you might not be able to tell people who are smoking marijuana on a regular basis. It’s not easy to tell, not unless they are really, really high. And that’s because they just get used to functioning while high.

So we need to ask about these questions so that we can protect the therapy hour, but also so that we know what’s happening when they’re trying to cope with negative events and feelings. You might be asking them to do something, using a tool, or like using a specific coping skill and if they tell you it doesn’t work. You kind of need to know if that’s, because they’re trying to do visualization while they’re high or while they’re drunk, or if they’re forgetting to use it because they’re using a substance or whatever. 

When something isn’t working in therapy, when someone isn’t making progress, even slow progress is fine, but if we’re not getting anywhere and I start thinking, huh? I don’t know what’s happening here. I feel like something should be moving. Usually that’s my signal to, I missed something. There’s a piece of this puzzle that I’m not seeing and I need to go back to the basics and figure it out. You can do this substance use history process on its own. And if you feel like you need to go back and revisit something, no problem.  

There are some more structured interview questions or structured assessment tools that you could use. Think about like a PHQ-9 or a GAD-7, but for using substances. There are a number of them, some better than others. And so I want to go over a few with you. I’m going to have links in the show notes as always to any relevant resources so that you can follow up if you need to.

So now as we start talking about assessments, the biggest one that people tend to use and that’s been around a long time is called the CAGE.  And it’s an acronym and it’s a little outdated in terms of what the acronym stands for. But I still find the questions pretty decent.

So cage stands for Cut Down, Annoyed, Guilty, Eye opener. So the first one is, have you ever felt the need to cut down on your substance use? Second, do you ever feel annoyed when people criticize your substance use? Three, have you ever felt embarrassed or guilty about your substance use? And four is the eye-opener. Have you ever used substances first thing in the morning?

So the eye-opener thing is kind of an old school phrase. That’s not something that we really say now it’s really kind of an AA phrase and. I don’t think colloquially that it’s really the term people use anymore for helping them wake up. I do think these questions are actually really useful. I do have them on my intake paperwork. Sometimes people check all nos and sometimes not. 

You’d be surprised though that some people end up checking one or two of those and most of the time, that’s a good indicator that there might be some problematic use. Once or twice I end up having somebody who checks those things and really, it was about like one or two incidents where they were drinking and something happened, but that they really don’t have a lot of problematic use. 

I find that having it on your intake paperwork is actually really helpful and it’s a real quick way to have it there as part of the conversation before you even end up seeing somebody. So there is a kid version of this called the Kiddie CAGE, which I don’t like, and I don’t use. 

I think a more useful measure is called the craft. That CRAFFT. They’re all Yes or No questions and there are six of them instead of the four for the CAGE.  On a newer version, there’s ones about nicotine and tobacco use as well. So this one is during the past 12 months that asks them to say how many days. And I don’t love that part because it’s asking them to do it over the last 12 months. And that’s really hard to quantify. They could say in an average month they might be able to say so, but over the 12 months, that’s going to be kind of hard.

All right. So for the CRAFFT, it stands for Car, Relax, Alone, Forget, Family and Friends and Trouble. So the first one is, have you ever ridden in a car driven by someone including yourself who was high or had been using alcohol or drugs? Do you ever use alcohol or drugs to relax, feel better about yourself or to fit in?  Three, do you ever use alcohol or drugs while you’re by yourself or alone? Four, do you ever forget things that you did while using alcohol or drugs?  Number five do your family or friends ever tell you that you should cut down on your drinking or drug use? And number six, have you ever gotten into trouble while you were using alcohol or drugs?

There are other measures that you can use. There’s one called a DAST which is a Drug Abuse Screening Test. There’s an adult and an adolescent version. There’s a Brief Screener for Alcohol, Tobacco, and Other Drugs.

There’s one called Helping Patients Who Drink Too Much. A Clinician’s Guide. There’s an Opioid Risk Tool. And lately SAMHSA has been talking about what’s called SBIRT, which stands for Screening Brief Intervention and Referral to Treatment for Substance Use. So there’s a couple of steps to SBIRT and there’s training, usually that goes along with it.

So first there’s a pre screening form that they believe should be administered to all adult patients. You’re supposed to rule out patients who are at low or no risk  using one pre screening question for alcohol and one for drugs. Lately, I think government entities have been wanting these really simple two question things. So like there’s a PHQ-2 instead of a PHQ-9. And if the PHQ-2 is positive, then they give the PHQ-9. So it’s kind of like that. 

The first question is by gender because that’s different for alcohol consumption. Basically the question is how many times in the past year have you had four or more drinks in a day for women or five or more drinks in a day for men?  And the answers are either none or one or more. The idea is either you’ve had more than four or five drinks in a day, or you haven’t. They’re trying to screen out people who basically don’t drink very often, don’t drink at all, or don’t drink to excess. 

The second question is how many times in the past year have you used a recreational drug or used a prescription medication for a nonmedical reason? And again, the answers are none or one or more times.

Then based on the prescreening tool, if somebody was positive for alcohol, then they’ll use what’s called the AUDIT, which is an Alcohol Screening Tool. If they were positive for the drug question, then they’ll use the DAST. If it’s a youth or someone under 18, then there are some other ones that they use.

Once they’ve been screened, then they take the patient through the brief intervention process.  And in that process, they raise the subject, ask permission to talk about it, provide feedback about the screening questionnaires they use. Then they talk about the pros and cons  of somebody’s substance use and their readiness to talk about it or make any changes. And then talk about what our next plan would be.

So the SBIRT is meant to be used in medical settings typically, but there are a lot of therapy practices who’ve used it as well. You can get the information online and take a look at it for yourself.  Again, I’ll include links in the show notes. 

I personally don’t use these assessment tools. And part of that is it’s not really my nature to do so. I use the PHQ-9 and the GAD-7 on occasion, mainly when I want to quantify something and I’m having trouble getting the client to talk about specific feelings. That’s usually with my younger high schoolers who have trouble articulating that.  

Sometimes I’ll use it because I want to share it with a primary care doctor as some backup for what I’m saying when I refer them for medication, but I typically don’t use the substance use ones except for the CAGE  in my intake packet. And that’s just a personal preference. But whatever works for you is just fine. If you’d rather get some idea what their substance use history is at the outset, that’s a great way to go. Whatever is going to help you feel more comfortable bringing substance use into the room. I’ll make sure that all those links are there. 

The substance use history is meant to give you some context. It gives you context about what was happening in their life. It gives you context about whether or not they have any bad experiences with substance use or whether they’ve used it to cope and how they’re doing now. 

There are a lot of implications for long-term substance use or even intense substance use that isn’t necessarily long standing on what we’re doing. For instance, someone who’s been using meth, even if they’ve quit, is going to have dopamine receptors that are fried and will take up to two years to restore. That is extremely difficult and will have huge implications for therapy.

If someone’s been drinking for a long time, they could have some issues with memory and cognition. There can be some shrinkage of the brain. There’s a lot of complications too, depending on the type of thing a person’s using. So  that’s the main reason behind getting a substance use history.

However you choose to do it. I hope that all of this information that we’ve been talking about is helpful in how to set up the conversation, and how to protect the therapy hour. What we’re looking for when we say we’re using a substance use lens. And that we’re just adding that lens to the other ones that we already use. It’s not a replacement for any of our other lenses. And talking about how to get the substance use history in terms of asking questions like when was the first, when was the worst and when was the last time they used that substance? 

In the next podcast, I’m going to talk about scenarios that I have heard, and that have been brought to me and talk about whether or not something feels concerning or not when it comes to substance use, I know that I won’t be able to predict every situation that you might encounter, but I’m hoping that hearing how I talk about different scenarios and why I find that to be concerning or not concerning and what would elevate it to a concerning level. I’m hoping that that would be really helpful. 

If you ever have thoughts or questions about things you’d like me to talk about, I really do love hearing from people. Unless it goes through a spam folder and I miss it, I do always answer and I would love to hear what it is that you have questions about. Feel free to send me an email to betsy@betsybyler.com. I hope to see you on the next podcast and until then have a great week.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know.  Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

Helpful Links

Drug Use Screening Tests: MedlinePlus Medical Test

Screening and Assessment Tools Chart | National Institute on Drug Abuse (NIDA)

Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool

CRAFFT-Adolescent Substance Use Screening

CAGE-AID Substance Abuse Screening Tool | Official web site of the U.S. Health Resources & Services Administration

Alcohol Use Disorders Identification Test (AUDIT)

Instrument: Drug Abuse Screening Test (DAST-10) | NIDA CTN Common Data Elements

Screening, Brief Intervention, and Referral to Treatment (SBIRT) | SAMHSA

Assessing Addiction: Concepts and Instruments

Clinical assessment of substance use disorders – UpToDate

The Clinical Assessment of Substance Use Disorders

Resources for Screening, Brief Intervention, and Referral to Treatment (SBIRT) | SAMHSA

NCDAS: Substance Abuse and Addiction Statistics [2022]