The 7 Core Questions Every Clinician Should Ask About Substance Use
This is Part 5 in our series on Substance Use History.
Read Part 4: How to Ask About Substance Use in a Way That is Both Medically Precise and Deeply Compassionate for the previous component.
Universal questions form the backbone of substance use assessment, applicable across all substance categories. These seven core domains provide comprehensive framework ensuring systematic evaluation regardless of which substances patients use. Subsequent posts will add category-specific questions for alcohol, opioids, stimulants, cannabis, and other substances, but mastering these universal questions establishes foundation for all substance assessment.
These core questions apply to every substance and provide the scaffolding for later category-specific assessment. They balance medical data collection with psychological understanding, embodying the dual-purpose framework presented in previous posts.
Learning Objectives
After reading this section, you should be able to:
- Identify the seven universal assessment domains applicable to all substances
- Elicit initiation context revealing triggers and underlying pain
- Assess usage patterns including frequency, quantity, and co-use
- Explore quit attempts and relapse patterns informing treatment planning
- Evaluate functional consequences and psychological role of substance use
💡 Clinical Pearl: The Power of “Experimented With”
Use “Have you ever experimented with [substance]?” as your opening question for each substance rather than “used” or “tried.” The word “experimented” is psychologically less loaded. It implies curiosity and exploration rather than problem use or commitment. “Used” sounds accusatory, “tried” implies you’re looking for problems, but “experimented with” normalizes exploration and sounds genuinely curious.
This subtle linguistic shift can be the difference between a patient who minimizes and one who tells you the truth. The word choice signals that you understand substances as attempts to solve problems or manage pain, not moral failures requiring judgment. Patients respond to this nuance even if they cannot articulate why the question feels safer.
Domain 1: Initiation and Context
These questions assess how substance use began, revealing psychological function and situational triggers.
- “When did you first start using [substance]?”
- “What was going on in your life when you started – were you with friends, trying to manage something, curious about the experience?”
- “How long have you been using overall, including any periods where you stopped?”
Clinical rationale: Understanding initiation context reveals what problem the substance initially solved. Someone who started drinking at 13 after parental divorce used alcohol differently than someone who started social drinking at 21 in college. Childhood initiation often indicates more severe underlying pain, trauma, or family substance use. Adult initiation may reflect situational stress, peer influence, or experimentation.
The circumstances of first use predict current function. Starting cocaine to manage untreated ADHD differs from starting to enhance partying. Starting benzodiazepines prescribed for anxiety differs from obtaining them illicitly to manage withdrawal. Initial context illuminates current relationship with the substance.
Domain 2: Pattern and Frequency
These questions quantify use patterns for medical risk assessment and severity determination.
- “How often do you use – daily, weekly, monthly, or just socially?”
- “How much do you use on a typical day or during binges?”
- “Do you typically use alone or with others? At home or in public?”
- “Do you use [substance] along with alcohol, tobacco, or other substances?”
- “When was your last use?”
Clinical rationale: Frequency and quantity determine medical risk. Daily use creates physiologic dependence and withdrawal risk that weekly use does not. Quantity affects overdose danger and medical complications. Someone drinking 3 drinks weekly faces different risks than someone drinking 15 drinks daily.
Context of use (alone versus social, home versus public) reveals functional role. Using alone often indicates self-medication rather than social enhancement. Using at home suggests managing internal states. Using in public may indicate social anxiety relief or peer-driven use.
Polysubstance use amplifies risk exponentially. Alcohol plus benzodiazepines causes respiratory depression neither alone produces. Cocaine plus alcohol creates toxic cocaethylene metabolite. Opioids plus sedatives dramatically increase overdose death risk. Co-use patterns must be assessed systematically, not assumed based on primary substance.
Last use timing determines immediate withdrawal risk and whether intoxication affects current presentation. Someone who used alcohol 6 hours ago may be withdrawing now. Someone who used cocaine 2 hours ago may still be intoxicated, affecting mental status exam reliability.
Domain 3: Quit Attempts and Relapse
These questions reveal motivation, barriers, and treatment response patterns.
- “Have you tried to quit before? How many times?”
- “What happened when you tried to quit?”
- “What methods did you use to try to quit – medications, counseling, support groups, cold turkey?”
- “How long have you been able to remain sober? How often has that occurred?”
- “What led to starting again each time?”
Clinical rationale: Quit attempt history reveals motivation level, insight, and treatment responsiveness. Someone who has tried quitting multiple times demonstrates awareness that use is problematic and desire for change. Someone who has never attempted quitting may lack insight or readiness.
Methods tried inform future planning. If outpatient treatment failed repeatedly, higher intensity may be needed. If medications were tried but discontinued due to side effects, different pharmacotherapy or dose adjustment may succeed. If person never received evidence-based treatment, connecting them with appropriate interventions offers new hope.
Sobriety periods demonstrate capacity for abstinence. Someone who achieved 2 years sober shows they can maintain recovery with appropriate support. Someone who cannot sustain more than a few days sober may need medical detoxification or residential treatment providing external structure.
Understanding relapse triggers guides relapse prevention. If stress reliably triggers use, stress management becomes treatment priority. If social situations trigger use, avoiding those contexts and building sober social networks becomes essential. If untreated psychiatric symptoms trigger use, addressing underlying conditions prevents relapse.
Domain 4: Route of Administration
This question assesses specific medical risks associated with how substances are used.
- “How do you use [substance] – smoking, injecting, snorting, swallowing, or another way?”
Clinical rationale: Route of administration creates distinct medical risks requiring targeted screening and intervention:
Injection use: Creates HIV, hepatitis C, and bacterial infection risks. Requires infectious disease screening, vaccination, sterile equipment provision, and wound care education. Collapsed veins, abscesses, endocarditis all result from injection practices.
Smoking/inhalation: Damages lungs and increases respiratory infection risk. Crack cocaine and methamphetamine smoking cause severe dental destruction and respiratory complications.
Intranasal use: Cocaine or crushed pills snorted cause nasal septum perforation, chronic sinusitis, and loss of smell.
Oral use: Safest route physiologically but slowest onset, leading some users to transition to faster routes increasing addiction severity.
Route also indicates addiction severity. Transitioning from oral to injection or smoking suggests tolerance development and escalating dependence. Most people don’t start with injection; progression to injection indicates advancing disease.
Domain 5: Withdrawal and Tolerance
These questions identify physiologic dependence requiring medical management.
- “What happens when you try to stop or cut back?”
- “Do you experience any physical symptoms when you haven’t used for a while – shaking, sweating, nausea, anxiety, trouble sleeping?”
- “Have you needed to use more over time to get the same effect?”
Clinical rationale: Withdrawal symptoms indicate physiologic dependence requiring medical detoxification for safe cessation. Alcohol and benzodiazepine withdrawal can be fatal without medical management. Opioid withdrawal, while not typically fatal, causes severe suffering driving relapse. Stimulant withdrawal causes depression and suicidal ideation.
Identifying withdrawal history predicts future withdrawal severity. Someone with history of severe alcohol withdrawal (seizures, hallucinations, delirium tremens) requires inpatient detoxification for subsequent quit attempts. Someone with mild withdrawal may safely detoxify outpatient with monitoring.
Tolerance development (needing increasing amounts for same effect) indicates neuroadaptation and advancing dependence. Tolerance predicts withdrawal severity and suggests intensive treatment may be needed.
Domain 6: Functional Consequences
These questions assess impairment across life domains, determining disorder severity.
- “Has [substance] use caused any problems with work, school, relationships, or your physical or mental health?”
- “Have you had legal issues related to substance use?”
- “Have you continued using despite knowing it was causing these problems?”
Clinical rationale: Functional consequences define substance use disorder severity. DSM-5 criteria include social/interpersonal problems, failure to fulfill major role obligations, physically hazardous use, and continued use despite problems. Systematic inquiry about each domain ensures comprehensive severity assessment.
The pattern of consequences reveals what the person is willing to sacrifice to maintain substance use, indicating addiction severity. Mild use disorder: continued use despite minor problems. Moderate: continued despite significant problems. Severe: continued despite devastating consequences including job loss, divorce, homelessness, serious medical complications.
Understanding specific consequences also informs treatment priorities. Legal consequences may create external motivation (court-mandated treatment). Relationship problems may indicate need for couples therapy. Work impairment may require disability accommodations or vocational rehabilitation.
Domain 7: Function and Psychological Role
This question explores the core psychological function driving use.
- “What role does [substance] play for you?”
- “What does [substance] do for you that nothing else can?”
Clinical rationale: This open-ended question helps patients reflect on substance function, something many haven’t consciously considered. It eases tension by moving from potentially judgmental questions about consequences to genuine curiosity about their experience.
Patients reveal substances serve specific psychological functions: coping with depression, managing anxiety, treating insomnia, numbing emotional pain, enhancing social comfort, providing energy, escaping trauma memories. Understanding function is essential for treatment planning because you cannot simply remove the substance without addressing the underlying need.
If alcohol treats anxiety, anxiety treatment becomes primary. If cocaine manages untreated ADHD, stimulant medication may reduce cocaine cravings. If opioids numb childhood trauma pain, trauma therapy addresses root cause. If cannabis is the only way someone sleeps, sleep medicine consultation prevents relapse from insomnia.
Function also reveals readiness for change. Someone who views their substance use as purely positive (“Meth makes me feel alive and I don’t want to stop”) requires motivational interviewing before action-oriented treatment. Someone who recognizes ambivalence (“Alcohol helps my anxiety but it’s ruining my marriage”) demonstrates readiness for change-focused interventions.
Integration Across Domains
These seven domains form interconnected assessment revealing both medical risk and psychological meaning. Consider how answers across domains inform each other:
A 35-year-old reports:
- Started using opioids at age 16 after car accident (Domain 1 – early initiation, pain connection)
- Currently uses heroin daily by injection (Domain 2 – high frequency, high-risk route)
- Tried quitting 6 times, longest sobriety 3 months in residential treatment (Domain 3 – multiple attempts, limited success)
- Experiences severe withdrawal with vomiting, shaking, pain when stopping (Domain 5 – physiologic dependence)
- Lost job due to attendance, divorced, estranged from children (Domain 6 – severe consequences)
- States “Heroin is the only thing that makes life bearable” (Domain 7 – psychological dependence)
Integration reveals: Severe opioid use disorder with early onset, significant physiologic dependence requiring medical detoxification, high-risk injection practices requiring harm reduction and infectious disease screening, multiple failed outpatient attempts suggesting need for residential treatment, devastating social consequences, and profound psychological dependence indicating need for comprehensive treatment addressing underlying despair. This patient requires intensive multimodal intervention: medical detoxification with medication-assisted treatment (buprenorphine or methadone), residential treatment providing structure and skills, mental health treatment addressing depression and hopelessness, and long-term recovery support.
The integrated assessment informs every clinical decision from detoxification setting to medication selection to treatment duration to relapse prevention planning.
Why This Information Matters
These seven core questions provide universal framework ensuring no critical assessment domain is overlooked regardless of which substances patients use. The systematic approach improves diagnostic accuracy, safety, and treatment planning while maintaining therapeutic alliance.
For comprehensive assessment: The seven domains ensure systematic evaluation covering initiation, current pattern, quit attempts, route-specific risks, physiologic dependence, functional consequences, and psychological function. Missing any domain leaves gaps affecting clinical decisions. Assessing only quantity without function leads to interventions ignoring underlying pain. Assessing only consequences without understanding physiologic dependence risks dangerous unsupervised withdrawal.
For treatment matching: Different domain findings indicate different treatment needs. Severe withdrawal history requires medical detoxification. Injection use requires infectious disease screening and harm reduction. Multiple failed quit attempts suggest higher intensity treatment needed. Functional role reveals what underlying condition requires treatment. Systematic assessment across all domains ensures comprehensive treatment recommendations addressing the full clinical picture.
For rapport and disclosure: The structure of these questions balances medical data collection with psychological exploration, demonstrating you care about both safety and understanding. Starting with initiation context before asking about current quantity feels less threatening than opening with “How much do you use?” The functional question invites reflection rather than defensiveness. This balance facilitates honest disclosure.
For clinical efficiency: Having universal framework applicable across substances streamlines assessment. Rather than developing different approaches for each substance, these seven domains provide consistent structure. Fluency with this framework allows focusing on listening rather than remembering which questions to ask.
For teaching and supervision: The seven-domain structure provides clear teaching framework for students and trainees. Supervisors can review documentation ensuring all domains were assessed. Trainees can practice with standardized structure before developing personalized interview style.
These core questions establish foundation. Subsequent posts will layer category-specific questions for alcohol, opioids, stimulants, cannabis, sedatives, and other substances onto this universal framework, creating comprehensive yet systematic assessment approach applicable across all clinical settings.
Next in this series:Â Each individual substance of abuse…
Previous post: Part 4 – How to Ask About Substance Use in a Way That is Both Medically Precise and Deeply Compassionate
