Substance Abuse Assessment Template

A substance abuse assessment template refers to a process that is carried out to get an insight into the history and ongoing abuse of substances by patients. This assessment is carried out to get a clear understanding of the patient’s condition and find the best possible treatment for them. It is extremely important to know what substances the patient has used or has been using to make sure the treatment does not cause an adverse side effect on their body. The amount and consistency of use should be perceived to avoid side reactions that could possibly occur in the patient’s body. The substance abuse assessment helps the physician to determine how severe the medical problem is and whether it needs immediate treatment or slow treatment.

Why a Substance Abuse Assessment is Crucial?

Other than the amount and consistency, other related factors such as unusual social behavior due to abuse, psychological issues, mental health issues and any other reactions (allergies and weight loss) that the patient displays should be observed during the assessment. Also, in the case of past use of substances, whether the patient has ever been rehabilitated or relapsed. Keeping all these factors in view while performing the assessment helps the physician suggest proper therapy and medication for the patient.

Who should Conduct a Substance Abuse Assessment?

A substance abuse assessment should be conducted by someone who has specialized in that field to avoid an unfavorable outcome for the patient. Because patients who have been using substances such as drugs, alcohol or heavy dosages of antibiotics should be treated very carefully and cautiously. Such patients are prone to adverse side effects from different medications. Hence, the substance abuse assessment should be conducted by a substance abuse specialist (SAP) or by nurses who have specialized in drugs and narcotic addiction.

What are the Main Factors to Consider While Conducting a Substance Abuse Assessment?

Some of the main factors that the assessor should keep in view while analyzing the patient are as follows:

• The name of the substances that the patient has used (drugs, alcohol, narcotics, strong antibiotics).

• Psychological issues that most probably made the patient use substances such as depression, trauma, peer pressure or unknown issue.

• How frequently they use them.

• Any medical records because of the use of drugs.

• One of the main factors is to gain the patients’ perspective on the treatment. Whether they want the treatment to take place.

How to Formulate Results Using a Substance Abuse Assessment?

Once all these factors have been analyzed, it is time for the SAP or the nurse to find the treatment or result of the analysis. The result is formulated on the basis of these factors. When the assessor is conducting different methods to determine the best treatment, they should conduct a three-dimensional investigation into the patient’s environmental and social status. This is done by interviewing their family, close friends and associates about their habits and possible reasons behind their substance use. The reason why it is important to communicate with their associates is to ensure that the information provided by the patient is true, and they can continue to work on that information. Usually, the patients that are not looking forward to being treated are the ones that try to escape treatment by giving false information.

Templates for Substance Abuse Assessment:

gwep.usc.edu

nida.nih.gov

www.health.state.mn.us