Identification of Substance Use Disorder (SUD)

The National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA) recommend that physicians screen all patients over the age of 12 for substance use, misuse, and substance use disorder. Routine screening is important as substance use changes over time. Many clinics use a brief substance use screening tool like the CAGE-AID (age 18+) or CRAFFT (age 12-18):

• C—Have you ever thought you ought to cut down on your drinking or drug use?
• A—Have people annoyed you by criticizing you for your drinking or drug use?
• G—Have you ever felt bad or guilty about your drinking or drug use?
• E—Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?

The screening tool was originally designed to assess alcohol use; the AID stands for ‘adapted to include drugs’. The C is for cut down; the A is for annoyed; the G is for guilty; the E stands for eye-opener. The wording of the CRAFFT is slightly different, and validated for use with people 12-18 years of age.

Patients who are ready for chemical health treatment must get a Rule 25 Assessment (for patients with MA) or a chemical dependency assessment (for patients with private insurance). The Rule 25/CD Assessment is conducted by a CD Assessor who creates an Assessment Summary and Plan that is good for 45 days. The Rule 25/CD Assessment looks at:

• Acute intoxication/withdrawal potential
• Biomedical complications and conditions
• Emotional, cognitive, behavioral conditions and complications
• Readiness for change
• Relapse, continued use, and continued problem potential
• Recovery environment
• Client choices and exceptions
• Criteria for diagnosis
• Collateral contact summary

A variety of different roles, such as a Peer Support Specialist, Behavioral Health Integration Specialist, SBIRT Staff, or Care Coordinators, can provide wrap-around services to assist patients in getting into treatment. These services are reimbursable and/or funded through Health Care Home (HCH) (if the clinic is HCH certified, and the patient has at least one condition that is chronic, severe, and requires a care team), Behavioral Health Home (BHH) (if the clinic is BHH certified, and the patient is on MA and has at least one serious mental illness), SAMHSA Substance Abuse Expansion Grants, State Targeted Response (STR) Grants, or other funding streams. SAMHSA and the Health Resources and Services Administration (HRSA) promote Screening, Brief Intervention, and Referral to Treatment (SBIRT) services for coordinated care, transitions of care, and patient-centered care for patients with chemical health needs.   

Substance Use Disorders (SUD), including Opioid Use Disorder, are diagnosed using criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Referrals to behavioral health services (e.g. therapy, psychiatry), and/or chemical health services (e.g. detox, Rule 25, Chemical Dependency or CD Assessment) are often made long after a person would have been diagnosed or fit the criteria for an Opioid Use Disorder. As with most health conditions, early detection of symptoms of Opioid Use Disorder aids in supporting a patient’s recovery. The DSM-5 criteria for diagnosis of Opioid Use Disorder requires a minimum of 2-3 criteria for a mild substance use disorder. For example, if a patient is (1) taking the opioid in larger amounts and for longer than intended, and (2) having cravings or a strong desire to use opioids, they would meet criteria for a mild substance use disorder. Other criteria include wanting to cut down or quit but not being able to do it, or spending a lot of time obtaining the opioid. These symptoms are more regularly observed than they are diagnosed. Early detection of symptoms of dependence and/or addiction provide an opportunity for early intervention.

Rule 25/CD Assessments are limited to chemical health. They do not provide a thorough assessment or diagnosis for co-occurring mental health disorders. This requires an additional assessment, called a Diagnostic Assessment (DA), which is performed by a licensed mental health practitioner or psychiatrist.

Note: The Rule 25 process is under revision and expected to change by 2020. Beginning around July 2018, there were be a parallel process where people can seek treatment via (1) a Rule 25 at a placing authority-one of the 87 counties, 11 tribes, or some managed care organizations, or (2) direct access to the treatment center of their choice.

For resources about screening and Rule 25/CD Assessments, please go to the Resources tab.

Please visit the Opioid Dashboard for more information on opioid overdose death, nonfatal overdose, use, misuse, substance use disorder, prescribing practices, supply, diversion, harm reduction, co-occurring conditions, and social determinants of health.