E3.3

Substance Use History

Substances shape psychiatric presentation directly (intoxication, withdrawal, induced disorders) and indirectly (interactions, adherence, prognosis).

Encounter card

Setting

Every psychiatric encounter — substance use screening is non-optional.

Opening move

Normalize the questions. Ask about every category specifically rather than "any substances?" Use quantity-frequency questions for current use. Use timeline-followback for recent patterns.

Sample language

"I ask everyone about substance use — it's important for your medical care. How much alcohol do you drink in a typical week?"
"How about cannabis? Any other substances — cocaine, methamphetamine, opioids, prescription medications not as prescribed?"
"When was the last time you used? What was that like?"
"Have substances ever caused problems — health, work, relationships, legal?"

Listen for

Quantity, frequency, route, duration. Pattern (daily vs binge). Withdrawal history. Tolerance changes. Previous treatment attempts. Family history of substance use. The patient's own framing (problem vs not).

Common pitfalls

Asking "do you drink?" instead of "how much?" Accepting "occasionally" without quantification. Missing prescription misuse, IV use, polysubstance patterns. Treating disclosure with judgment that closes future disclosure.

Red flags / escalate: Active heavy alcohol use (withdrawal management). IV drug use (infection risk, overdose risk). Polysubstance use. Recent overdose. Pregnancy with active use. Concomitant BZD + opioid use.

Documentation

Quantity/frequency for each substance. Last use dates. Withdrawal history. Prior treatment.

Real-world reality: Adequate medication trials require sufficient visit frequency for monitoring. Insurance often pays per visit; the inadequately-monitored trial that produces "treatment resistance" is partly a system problem.

Substance use coexists with most psychiatric illness. Screening is mandatory; the conversation must be non-judgmental.

Warm grey-tinted clinical notebook page, sienna accent. Substance screening by category — alcohol, cannabis, stimulants, opioids, sedatives, prescription misuse. Margin clusters on each.

Substance use screening is mandatory in every psychiatric encounter. Substances shape psychiatric presentation directly (intoxication, withdrawal, induced disorders), indirectly (drug interactions, adherence problems), and prognostically (treatment response, relapse risk). The patient who is using substances and not telling you is being treated for the wrong condition, often unsuccessfully.

Normalize the question. "I ask everyone about substance use — it's important for your medical care." The framing matters. Substance use is asked without judgment, with the same routineness as asking about sleep. The patient who senses judgment closes the door to honest disclosure quickly.

Ask category by category. Alcohol. Cannabis. Stimulants (cocaine, methamphetamine, prescription stimulants used outside prescription). Opioids (heroin, fentanyl, prescription opioids used outside prescription). Sedative-hypnotics (benzodiazepines, z-drugs misuse). Hallucinogens. Inhalants. Tobacco and nicotine. Each category specifically; "any substances?" is too vague.

Quantify directly. "How many drinks in a typical week?" rather than "Do you drink?" "Occasionally" might mean monthly or might mean nightly; you need numbers. Days per week using cannabis, joints per day, drinks per week. Specific numbers matter.

Ask about prescription misuse specifically. The patient who answers "no" to "do you use illegal drugs" may take their spouse's Xanax, double their own oxycodone, or buy ADHD medication from a friend. Frame the question to capture these patterns: "Do you ever take medications differently than prescribed, or take medications that weren't prescribed to you?"

Pattern matters. Daily versus binge versus social. Recent change in pattern. Last use date. Withdrawal history. Prior treatment attempts. Family history of substance use disorder. Patient's own framing — does the patient see use as a problem?

Don't react with visible judgment when the patient discloses. The face that registers shock, disappointment, or worry tells the patient not to share more. Document specifics; bring nothing else to the disclosure beyond clinical attention.

Asking quantity-frequency specifically — drinks per week, days using, joints per day. Margin notes on why specific numbers matter.

The anchor

Substance use screening is mandatory in every psychiatric encounter. Ask category-by-category, quantify, and frame non-judgmentally to enable honest disclosure.

Framing substance questions non-judgmentally to enable honest disclosure — normalizing, specific, paced. Margin clusters on what creates safety.

Prove it

A patient with depression says "I drink socially, you know — wine with dinner." How do you proceed?

This connects to

D6.1

Alcohol Use Disorder (V2)

When use becomes disorder.

E8.2

The Intoxicated Patient

The acute encounter scenario.

Locked concepts unlock as you reach them on the path.