In this lesson, you will learn a concrete approach to conducting a robust substance use assessment. In teaching this course to medical trainees for close to a decade now, we've developed a framework or a mnemonic RIPTEAR that we think is helpful. To remember this mnemonic, we like to say with proper diagnosis and treatment, substance use disorders don't have to rip and tear your life apart. The RIPTEAR mnemonic will help you gather an organized concise yet thorough substance use history from a patient history that will guide the treatments that you recommend. With that, let's start with R, risk. When a patient with a substance use disorder is in front of you, the first thing to deal with is any acute issue, their risk for particularly poor outcomes if not addressed right up front. Things that constitute emergencies and substance use treatment include one, alcohol withdrawal. So this is your patient who has a history of complications of alcohol withdrawal with seizures or delirium tremens. Two, acute intoxication or a risk of overdose particularly those using opioids or other sedatives. Number 3, acute suicidality. These acute risks are associated with high mortality and should be top priority. So assess for these emergencies and refer to an emergency setting when needed. But of course, there are also other risks to our patients that we must keep in mind. When intoxicated, people may have impaired judgment and may engage in riskier behavior like driving a motor bike without a helmet or forgetting to follow safe sexual practices. Uncovering the likelihood of risk and checking for previous life traumas, infectious diseases, homelessness, food insecurity, and so on, are also important and are included in this risk section. I is next, this is for initiation. We want to know things like when did you first use the substance of discussion, when did you start using regularly? For example, every weekend. When did you first begin to recognize that this might be a problem for you? When was your period of heaviest use? These questions are going to give you a sense of the trajectory of the illness, has it been a short course from initiation of use to the first time when recognized that it may be a problem? Or has it happened gradually over decades even? We also want to know age of initiation because there's increasing recognition of the particular vulnerability of various developmental stages. In particular, adolescents and young adulthood is a high-risk period for the development of a substance use disorder. P is for pattern of use. It's likely that you will have uncovered some of this information in the screening process in their chief complaint or the history of present illness. This is the what, how, where, or when questions. Ask what exactly do you use, do you typically smoke crack cocaine or use powder cocaine? Are you overusing your prescribed hydrocodone or using street heroin? Do you drink only beer or is it mainly liquor? What type of liqueur? Ask how do you use it. Do you ingest it? Do you snort it, smoke it, inject intravenously? The route of administration is important in considering overdose risk as well as infectious diseases. If there's injection drug use, it should alert you to check for infectious diseases and to advise about the importance of clean needles and not sharing paraphernalia. Another how question is how do you buy it? That is, from a usual dealer or various ones. How do you get the money for drug use? Where do you use the substance? Only at a bar with other people or typically alone? Using drugs alone is a risk factor for overdoses as there is no one to potentially rescue the person where they'd lose consciousness. Additionally, many people start using a substance because of the social aspects of use. But as use becomes more problematic and less under control, it can become isolating. When do you use? Only on weekends, every day, in the morning, only on evenings? When are you with friends or when alone? When celebrating or when you feel sad or whenever you bump into that person who always had someones hand. So we've gone through the RIP portion of RIP-tear and covered risk, initiation, and pattern of use. Take a moment now to think about what else you would want to know about your patient and what other questions you might ask. The last four letters turn to the person's substance use disorder, treatment history, and their outcomes. T is for treatment as in past treatment. You want to ask if a person has ever had treatment, and if so what kind? Asks about a history of needing a medically managed withdrawal or detoxification, participation in any self-help programs, outpatient treatments, medication treatments, residential or in-patient treatments. If a patient answers yes, follow-up with more questions like which medications or how long were you there? When was this? Did you try this only once or many times? E is for effects of the substances used, both positive and negative effects. This will help you clarify the potential barriers and motivations for seeking treatment. Appreciating that there are both pros and cons to substance use, makes it easier to have a productive conversation. Particularly if you ask your patients about what effects they like such as improved sleep, less anxiety, avoiding withdrawal, feeling normal again. For example, if someone smokes cannabis to relieve anxiety, then it will help you problem-solve around other ways to relieve anxiety or maybe even prompt a discussion of how anxiety is provoked by cannabis withdrawal. Any negative consequences associated with the person's substance use can be explored as motivators to change. The more you understand about your patients effects or consequences of use, the better you'll be situated to determine a treatment plan. A is for abstinence and other emissions. For people with a substance use disorder, complete abstention from a substance is the safest most certain way to stop negative consequences and disease progression. That being said, abstinence is only one goal of recovery. Most self-help groups were founded by and targeted to people with severe substance use disorders from whom remission in the context of continued use is more difficult and less likely. Nonetheless, here, when we use the letter A for abstinence, don't forget to include other periods of remission, meaning times when a person did not meet criteria for a substance use disorder, whether or not they were occasionally using the substance in question. Ask questions like when were these periods of remission for you? What things were happening? What helped? Perhaps during those times, they were housed, employed, or their depression was well-treated. Perhaps they were taking medications or strongly engaged in a local self-help group. Occasionally, periods of remission have occurred during incarceration or hospitalization. When obtaining a history, dig deeper. Helping patients reflect on their own periods of remission and what were key factors allows us to brainstorm together what might help this time. For example, it seems medications have helped in the past. What are your thoughts about making that a part of your plan this time? Last but not least, our second R is for relapse or return to use. Relapse prevention involves looking ahead to any potential problems that might come your patient's way. Thinking about prior times when a return to use occurred is often helpful. So ask what happened when you returned to use, what was going on in your life at that time? Helping patients get specific is key here. You want to examine psycho-social circumstances. Was there a loss of a job, housing problems, or a traumatic experience? What were the medical or psychiatric comorbidities? Was there an untreated depression, an anxiety syndrome, or a pain condition that contributed relapse? Or was it a seemingly random event such as running into a particular person or particular mood states like anger, sadness, frustration that led to the relapse? When we know what things have been problematic in the past, we can better plan for these obstacles in the future. Relapse prevention is a crucial intervention to help people maintain their recovery. A protip here for asking all of these questions is to be really curious in a non-judgmental way. Ask plenty of follow-up questions because it's helpful to get a complete picture in order to make a recommendation. So that covers RIPTEAR, risk, initiation, pattern of use, treatment history, effects of substance-use, abstinence history, and relapse. As part of the full assessment, you also want to cover past psychiatric history, past medical history, social history, and family history. In closing, please keep in mind that treatment plan should be developed in collaboration with the patient and considering their preferences and their goals. Therefore, in our next lesson, we're going to turn to clarifying treatment goals which is an essential first step to determining a patient-centered treatment plan.
