Medical Evaluation

Different types of professionals are trained to assess people for addictions, including doctors, nurses, counselors, psychologists, therapists, and social workers. Typically, multiple people will evaluate you, especially if you are being cared for at an addiction treatment facility. This helps to ensure you receive the correct diagnosis for your condition and the best treatment possible.  Assessments often include questionnaires, physical exams, and self-assessment.

What is the Process of a Medical Evaluation?

The addiction assessment process is fairly straightforward. The doctor or clinician will have you fill out a standardized questionnaire asking about your current drug or alcohol use, treatment history, health history, patterns of behavior, symptoms, and the effects the addiction has had on your life. Afterward, the clinician will conduct a face-to-face interview with you, asking standard, open-ended questions that provide information to make a proper diagnosis.

Usually, the assessor takes notes, but any information given to the clinician is strictly confidential.

If a medical doctor conducts the assessment, there will likely be a physical examination. In addition to checking for the physical symptoms of addiction, the doctor may diagnose co-occurring health problems that need to be treated along with the addiction.

Psychologists, counselors, social workers, and other non-medical persons who perform drug and alcohol abuse assessments may refer you to a doctor for a physical evaluation. Co-occurring medical problems will impact how the addiction is treated, so it is important to be examined by a doctor as early as possible in the addiction assessment process.

A urine sample may be requested to test for the type of drugs you have consumed. Blood samples are usually not required but may be asked for if there is reason to believe the addiction has affected your health. For example, a blood test may be used to assess liver function in a person with an alcohol abuse problem.

The doctor or clinician will use the information obtained from the questionnaire, interview, physical examination, blood and urine tests, and their own clinical judgment to make a diagnosis. Objective criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) may also be used to assist in the addiction assessment. In addition, physicians may use training they have received specific to assessing substance use disorders.