Ask without judgement #
Ask about alcohol, tobacco, cannabis, opioids, stimulants, sedatives and other substances, including medicines taken differently from instructions, over-the-counter products and supplements. Use locally understood names and clarify composition where possible. A labelled or street product may have uncertain contents. Explain that these questions help interpret symptoms and plan care. Specific patterns may be easier to disclose than an answer to whether someone has a drug problem.
- Which substances or medicines do you use to relax, stay awake, sleep or change how you feel?
- What do you call the product, and how do you take it?
- What would you like help with concerning your use?
Build a separate exposure timeline #
For every substance record first use, circumstances, progression, route, frequency, usual amount, maximum amount, last use and recent changes. Distinguish experimentation from the current pattern. Record combinations and their sequence. Ask about source and variability when composition is uncertain. For alcohol, document beverage type, volume and strength: 'two drinks' is insufficient because serving sizes differ. Do not interchange national definitions of a unit or standard drink.
| Field | Question |
|---|---|
| Amount | What bottle or measure, what strength, and how much? |
| Pattern | Daily, weekends, binges or particular settings? |
| Route | Swallowed, smoked, inhaled, injected or another route? |
| Recent use | When was the last amount; was it usual for you? |
| Combination | What else was taken, including prescribed medicines? |
Control, priority and adaptation #
Explore difficulty starting, limiting or stopping use; time spent obtaining or recovering from it; and activities that have become less important. Ask about craving, tolerance and symptoms after reduction or cessation. Determine whether another dose relieves those symptoms. Interpret these experiences in their substance and medical context. Do not use an older diagnostic threshold as a universal contemporary rule or treat one answer as an automatic diagnosis.
- Have you used more or for longer than intended?
- What happens if you delay or reduce it?
- Have you needed more for the same effect?
- Which activities have you given up or missed because of use?
- What made previous attempts to change easier or harder?
Consequences and symptom relationships #
Enquire about blackouts, falls, accidents, overdose, seizures, injuries, infections and physical problems. Explore work, study, money, caregiving, relationships and legal consequences without moral labels. Ask about mood, anxiety, perceptions, sleep and cognition before use, during intoxication, after reduction and during sustained abstinence. Records and collateral observations can clarify chronology. Temporal association does not itself establish whether a psychiatric condition is induced, independent or aggravated by substances.
| Term | Assessment focus |
|---|---|
| Intoxication | Recent exposure and observed state; consider other medical explanations. |
| Withdrawal | Symptoms after reduction, previous episodes and complications. |
| Tolerance | Change in the amount needed or effect over time. |
| Blackout | A recall gap; clarify consciousness and injury rather than equating it with fainting. |
| Abstinence | Actual duration without use, support and symptoms during it. |
Important assessment priorities #
Identify previous withdrawal-related seizures or severe confusion, current physical state, medical illness, pregnancy where applicable and concurrent exposure. Ask about previous overdose and access to emergency assistance. Screening and symptom scores support assessment but do not replace examination or establish the appropriate setting. Reduced consciousness, severe confusion, seizures or acute physical deterioration require urgent clinical assessment.
Previous change, treatment and goals #
Explore periods of reduced use or abstinence, duration, circumstances, treatments, support and return to use. Ask what worked rather than documenting only failed attempts. Establish goals, confidence and concerns. Readiness varies between substances and over time; it is not a fixed personality trait. Include withdrawal fears, unstable housing, cost, pain, social networks and coexisting symptoms as possible barriers.
- What was different during the longest period of reduced use?
- Which support was useful, and what felt unhelpful?
- What change matters most to you now?
Synthetic example and documentation #
A fictional driver reports nightly drinking and missing work after mornings with shaking. Clarification establishes beverage size and strength, last use, whether drinking relieves shaking, and a previous seizure after stopping. The interviewer documents reported concerns, checks current physical findings and arranges clinician-led assessment of withdrawal needs. They do not calculate a home withdrawal plan or assume calm behaviour establishes safety. The record distinguishes self-report, observed signs, confirmed events and outstanding information.