Stop Asking “Have You Ever Used?”: Why Substance Use Requires Real Clinical Assessment
This is the introductory post in our series on Substance Use History.
Most of what you’ve learned in medical school about assessing substance use probably boils down to a single line: “Have you ever used any drugs or alcohol?” That’s not your fault – it’s how the topic is often glossed over in curricula. But let’s be clear: for a psychiatric assessment, relying on that question alone is like asking a cardiology patient, “So… your heart okay?” and calling it a full workup.
That single question tells you almost nothing. It’s vague, binary, and completely misses the nuance, pattern, and context that define substance use disorders. Psychiatry – like the rest of medicine – depends on detail, chronology, and impact.
Learning Objectives
After reading this section, you should be able to:
- Explain why single yes/no substance questions are clinically inadequate
- Identify key domains required for a comprehensive substance use history
- Apply the “chest pain equivalency” framework to teach structured assessment
- Recognize how superficial screening undermines diagnostic accuracy and rapport
Why “Have You Ever Used?” Is Inadequate
A patient can truthfully answer “yes” or “no” without giving you any clinically useful data. It doesn’t tell you:
- What substance they used (alcohol, cannabis, stimulants, opioids, etc.)
- When they used it (college experimentation vs. last night)
- How much they used
- Route of use (oral, intranasal, IV, smoked)
- Consequences (legal, social, medical, psychiatric)
- Attempts to quit and withdrawal symptoms
This is the difference between a question and an assessment.
The Cardiology Analogy: What Real Assessment Looks Like
In cardiology, asking “Have you ever had chest pain?” and stopping there would get you laughed out of rounds. You’d need onset, character, duration, radiation, relieving/exacerbating factors, associated symptoms, and functional impact.
In infectious disease, you wouldn’t ask, “Have you ever had a fever?” and then move on. You’d ask when, how high, how long, and what else came with it.
In neurology, asking “Have you ever lost consciousness?” without clarifying seizure vs. fainting vs. intoxication would make your attending’s eye twitch.
The psychiatric equivalent: Substance use history needs the same precision.
The Chest Pain Equivalency Table
To make this as clear as possible, here’s what each substance use question would be in cardiology:
| Substance Use History Element | Chest Pain History Equivalent | Why It Matters |
|---|---|---|
| Type, amount, frequency of each substance | Character, severity, frequency of pain (pressure? stabbing? intermittent?) | Just as the type and intensity of pain narrow your differential, knowing what substance and how much defines risk, toxicity, and potential diagnoses |
| Pattern over time (first use, escalation, current) | Onset, duration, course of chest pain (sudden vs. gradual, constant vs. intermittent) | You can’t understand disease trajectory without a timeline – both addiction and angina have progressive patterns that matter for management |
| Route of administration | ECG findings, cardiac biomarkers, and when indicated, coronary imaging and pathology | The specific route tells you what systems are involved and what complications to expect |
| Context of use (social, coping, alone, after stress) | Precipitating/relieving factors (with exertion? at rest? after meals?) | Context gives etiology – just as exertional pain suggests ischemia, solitary late-night use to “calm down” suggests self-medication |
| Consequences (DUIs, relationship loss, medical problems) | Associated symptoms (nausea, diaphoresis, dyspnea, syncope, radiating pain) | Consequences are the fallout that reveals severity. Associated symptoms and consequences both show system-wide impact |
| Attempts to cut down or quit | Previous evaluations/treatments (stress test, stent, medication response) | Prior efforts reveal chronicity and insight – whether the patient or system has already intervened, and with what outcome |
| Tolerance and withdrawal | Aggravating/alleviating factors (worse with exertion, better with rest/nitroglycerin) | Tolerance and withdrawal describe the body’s physiologic adaptation – just like how ischemic pain worsens or eases with certain triggers |
| Periods of abstinence and relapse triggers | Recurrent or stable pattern (first episode vs. recurring angina) | Both describe whether the problem is episodic, chronic, or in remission – critical for prognosis and treatment planning |
Why This Information Matters
If your entire substance use history consists of asking “Have you ever used any drugs or alcohol?”, your psychiatric assessment is essentially equivalent to conducting a neurological exam by asking “Can you walk?”, taking a sexual history by asking “So, uh, you sexually active?”, or assessing sleep by asking “You sleep sometimes?”
A thorough substance use assessment is not optional extra detail – it’s fundamental to psychiatric diagnosis and treatment planning. Substance use disorders are among the most common psychiatric conditions, frequently co-occur with other mental illnesses, profoundly affect treatment response, and carry significant morbidity and mortality. Superficial screening fails on multiple levels.
Diagnostic accuracy suffers when you miss active substance use that mimics or exacerbates psychiatric symptoms. Stimulant use can look like mania or anxiety. Alcohol withdrawal can present as depression with agitation. Chronic cannabis use in adolescents increases psychosis risk. Without detailed substance history, you may misdiagnose primary psychiatric illness, prescribe medications that interact dangerously with substances, or miss opportunities for life-saving interventions.
Treatment planning becomes guesswork without understanding the role substances play in the patient’s life. Does the patient use alcohol to self-medicate depression, or does alcohol cause the depression? Is anxiety driving benzodiazepine misuse, or is benzodiazepine withdrawal causing anxiety? Are stimulants being used to treat undiagnosed ADHD? These questions fundamentally alter your treatment approach, yet they’re unanswerable without comprehensive assessment.
Therapeutic rapport depends on demonstrating genuine interest in the patient’s full story. Patients recognize when clinicians are checking boxes versus truly trying to understand their lives. Asking thoughtful, detailed questions about substance use – with curiosity rather than judgment – communicates that you see them as a whole person rather than a diagnosis to be stamped and moved along. This rapport is not a luxury; it’s the foundation that allows patients to be honest about sensitive topics like continued use, failed quit attempts, or consequences they’re ashamed of.
Risk assessment requires specificity about which substances, what amounts, and what patterns. The risk profile of daily IV heroin use differs dramatically from weekend cannabis use, yet both patients might answer “yes” to “Have you ever used drugs?” Understanding route of administration, co-use patterns, and high-risk behaviors allows appropriate infectious disease screening, overdose prevention counseling, and harm reduction interventions that save lives.
A real clinician doesn’t stop at the yes/no. The story behind the “yes” is where the medicine – and the humanity – actually lives. This series will teach you how to gather that story systematically, interpret it accurately, and use it to guide evidence-based treatment. The substance use history is not an afterthought; it’s a cornerstone of comprehensive psychiatric assessment.
Next in this series: Part 2: ***
