Substance Use Disorders

Clinical Components of a Written Report by the Treating Physician

• Acknowledgement of prior review of the job description;
• Review of medical documentation and/or collateral interviews (e.g., co-workers, supervisors, or family), performance evaluations, disciplinary actions, etc.;
• Medical and psychiatric history;
• Occupational/military history;
• Physical examination;
• Mental status examination;
• Results of brief cognitive screening tests*;
• Referral for more comprehensive cognitive screen if required. In cases where the MoCA score is normal (i.e., 26 and above), but the clinical impression suggests clinical impairment is present, further neuropsychological testing may be indicated.
• Results of psychiatric screening questionnaires**;
• Laboratory investigation;
• Diagnostic formulation as per DSM-IV-TR, including any appropriate substance use abuse or dependence remission modifiers;
• Coping skills evaluation, family and social supports;
• Treatment recommendations including recommendations for continued relapse prevention;
• Monitoring recommendations including type, duration and frequency (see Appendix C, section 7);
• Assessment of co-morbidities and long-term adverse conditions (see Appendices C-4 and C-8); and
• Prognosis and risk of relapse (see Appendix C, section 6).

See Appendix G for an evaluation form for the treating physician if this is used in lieu of a written report.

*The Montreal Cognitive Assessment (MoCA) may be used in identifying potential cognitive impairment among substance use disorder patients. (Using a cut-point score of 25, the sensitivity for substance use disorder is 83% and specificity is 73%.)

**Examples include the Patient Health Questionnaire-9 (PHQ-9) for major depressive disorder, and the GAD-7 for generalized anxiety disorder.