What is the optimal approach for a psychiatric nurse practitioner to conduct a substance‑use disorder assessment within a ten‑minute interview?

Optimal 10-Minute Substance Use Disorder Assessment Approach

Start with the single-question screen: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" which takes less than 30 seconds and has 90-100% sensitivity for detecting substance use disorders. 1

Step 1: Universal Single-Question Screen (30 seconds)

• Ask every patient the validated single question regardless of presentation 2, 1
• Any response of 1 or more times is considered positive and requires further assessment 1
• If clarification needed, add: "For instance, because of the experience or feeling it caused" 2
• This approach demonstrates 90-100% sensitivity and 74% specificity 2, 1

Step 2: If Positive - Administer DAST-10 (2-3 minutes)

For any positive single-question screen, immediately follow with the Drug Abuse Screening Test-10 (DAST-10) to quantify risk level. 1

• The DAST-10 is a self-report instrument with 90-100% sensitivity and 77% specificity 2, 1
• Score interpretation: 0 points = low risk; 1-3 points = moderate risk requiring monitoring; >3 points = substance abuse or dependence 2, 1
• Can be self-administered while you document, saving interview time 2

Step 3: Risk Stratification and Targeted Assessment (3-4 minutes)

Based on DAST-10 score, stratify into one of three categories that directly determine your intervention:

Hazardous Use (DAST-10: 1-3 points)

• Assess frequency and context of use 2, 1
• Identify high-risk substances: heroin, methamphetamine, crack cocaine carry intrinsically high harm risk regardless of frequency 2, 1
• Ask about consequences: legal issues, relationship problems, work/school impact 2

Substance Abuse (DAST-10: >3 points without dependence criteria)

• Screen for DSM criteria: failure to fulfill obligations, use in hazardous situations, legal problems, continued use despite social/interpersonal problems 1
• Ask: "Has your use caused problems at work, school, or home?" 2
• Ask: "Have you used in situations where it was physically dangerous?" 2

Substance Dependence (DAST-10: >3 points with dependence features)

• Rapidly assess for 3+ of these criteria: tolerance, withdrawal, loss of control, persistent desire to quit, time spent obtaining/using, reduced activities, continued use despite problems 1
• Ask directly: "Do you need more to get the same effect? Have you had withdrawal symptoms?" 1

Step 4: Screen Critical Comorbidities (2-3 minutes)

• Mental illness screening is mandatory - depression and anxiety commonly co-occur and affect treatment success 1, 3
• Ask about intimate partner violence, which is highly prevalent in substance use disorders 1, 3
• For women of childbearing age, assess pregnancy status and contraception 2

Step 5: Maintain Non-Judgmental Approach Throughout

Use the same matter-of-fact tone you would for discussing an abnormal glucose test - substance use disorder is a medical condition, not a moral failing. 2

• Avoid stigmatizing terms like "addict" or "clean" 2
• Frame as: "I'm here to offer care and treatment for a clinical condition" 2
• Explain that substance use disorder is treatable and treatment is safe 2

Critical Pitfalls to Avoid

• Never skip screening due to time constraints - the single question takes 30 seconds and universal screening is justified by high prevalence and morbidity 1
• Never use informal questioning instead of validated tools - only 1 in 3 physicians who report screening actually use validated instruments 4
• Never order routine urine drug testing for screening - reserve this for confirming suspected diagnosis or monitoring treatment, not initial assessment 2, 1
• Never allow fear of being manipulated to cloud judgment - apparent drug-seeking often represents pseudoaddiction from undertreated pain or therapeutic dependence 3
• Never break confidentiality unless there is acute danger - assure patients that disclosure will not be shared unless immediate risk of harm exists 2

Special Population Considerations

Adolescents (if applicable to your practice)

• Use CRAFFT tool instead of DAST-10, which takes average 74 seconds for provider administration or 49 seconds for computer self-administration 4
• Excuse parents from room to ensure confidentiality and improve response accuracy 2
• Federal and state privacy laws entitle adolescents to confidentiality regarding substance use treatment 2

Pregnant Women

• Use NIDA Quick Screen (4 questions) or 4Ps tool, which are validated and publicly available 2
• Emphasize that treatment is safe and encouraged during pregnancy 2
• Be aware of local mandatory reporting laws before detailed assessment 2

Documentation and Next Steps

• Document risk category (hazardous use, abuse, or dependence) to guide intervention intensity 1
• Hazardous use: brief counseling and ongoing assessment 2, 1
• Substance abuse: brief counseling, negotiate plan, close follow-up 2, 1
• Substance dependence: brief counseling, referral for specialty treatment, consider pharmacotherapy 2, 1