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Red Flags for Substance Use Disorders

Despite good interview skills and use of effective screening tools, many patients with serious substance use disorders escape identification in physicians’ offices. Attending to behavioral and physical red flags will help you identify a significant subset of patients who would otherwise remain “under the radar,” and thus not benefit from intervention.

Patients with substance use disorders are often reluctant to reveal them. They may fear negative judgments, be embarrassed about their inability to control their lives, or be in denial about the extent of their problems. In a variety of subtle or not-so-subtle ways, patients effectively avoid disclosure. Their methods include not listening to questions; minimizing use or consequences of use; changing the topic; showing irritation, anxiety, or other symptoms that discourage further inquiry; blocking many facts from their own consciousness; and outright lying

Please click the video buttons on the left to see what Reno and Rhonda have to say about interactions with their doctors.

However, there may be signals that appear in an interview, during the physical exam, in prior records or in statements from significant others, office staff, or hospital staff, that raise concern about a patient’s substance use. These “red flags,” whether mentioned by the patient, family, or another information source, should be an indication to follow up with the same diligence and persistence as you would after a positive drug screen or disclosure of heavy substance use, in order to ascertain the presence of a substance use disorder and the patient’s readiness to accept treatment.

Some common “red flags” are in the bulleted list below.

Physical findings: Alcohol on the breath, ascites, an enlarged liver, nasal ulcers or a perforated septum, excoriated skin (from scratching), track marks, skin abscesses, obesity or anorexia, abnormal gait, tremor, slurred speech, change in pupil size, injuries, chronic pain, blackouts, accidental overdoses, withdrawal symptoms, other liver or gastrointestinal problems, premature labor, and vague somatic complaints.
Mental symptoms: Depression, anxiety, flashbacks, insomnia, suicidal behavior, paranoia, irritability, vagueness, hallucinations, memory and concentration problems, and defensiveness about questions relating to substance use.
Social Problems: Isolation/withdrawal, loss of previous friendships, marital difficulty including domestic violence, and loss of interest in prior activities (e.g., sports, hobbies).
Education and employment history: School failure or poor grades, job losses, and frequent job changes.
Legal problems: DUI, assaultive or violent behaviors, stealing, drug possession, and prostitution.
Family history: May be positive for substance use or mental disorders; developmental problems in children.