Substance Use Disorders

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Evaluation Form for the Treating Physician

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Introduction:

The well-educated and well-motivated law enforcement officer (LEO) with a substance use disorder in remission can be capable of safe and effective job performance. An individualized clinical evaluation of the LEO’s substance use disorder should be performed to determine whether the individual’s condition permits safe and effective job performance. Such evaluation must include the following key elements, which are discussed in detail below:

  • Acknowledgement of prior review of the job description
  • Medical and psychiatric history
  • Review of medical documentation and/or collateral interviews (e.g., coworkers, supervisors or family)
  • Physical examination
  • Mental status examination
  • Results of brief cognitive screening tests[1]
  • In cases where the MoCA score is normal, i.e. 26 and above, but the clinical impression suggests clinical impairment is present; further psychological testing may be indicated.
  • Results of psychiatric screening questionnaires[2]
  • Laboratory investigation
  • Diagnostic formulation as per DSM-IV-TR, including any appropriate substance abuse or dependence remission modifiers
  • Coping skills evaluation
  • Treatment recommendations including recommendations for continued relapse prevention
  • Monitoring recommendations including type, duration and frequency
  • Assessment of co-morbidities and long-term adverse conditions
  • Prognosis and risk of relapse

Any problem with alertness, attention, insight, judgment, orientation, mood and psychomotor function must be reported.

Assessment:

The LEO should be under the ongoing care of an addiction specialist physician or other clinician knowledgeable regarding substance use disorders. Outpatient and inpatient record(s) of the last three years or since the date of the diagnosis (whichever is shorter) should be reviewed by the treating physician and forwarded to the police physician.

My credentials as a physician knowledgeable about substance use disorders are as follows (or attach CV):

___________________________________________________________________

___________________________________________________________________

Medical and Psychiatric History
Substances used/abused (check all applicable):

  • Alcohol
  • Caffeine
  • Cannabis [Marijuana/THC] (medicinal, “prescription,” legal, or illicit)
  • Cocaine
  • Hallucinogens (PCP, ketamine, and other hallucinogens)
    Inhalants
  • Opioids (either Prescription or “Street”)
  • Sedative-hypnotic/anxiolytics (e.g., Benzodiazepines)
  • Stimulants, e.g. amphetamines (either prescription or “street”, including crystal methamphetamine, MDMA and other MDA derivatives
  • Tobacco
  • Other (e.g., Anabolic Steroids and Androgens)

Specify: _________________________________________________________

Substance use history:

______ Mode of use (e.g., smoking, snorting, injecting, other –please explain):______

______ Quantity used: ______

______ Frequency of use: ______

Pattern of use (include date of last drink or drug used, duration of sobriety, longest abstinence:

_______________________________________________________________________

Previous substance use disorder treatments: ___________________________

Number of withdrawal episodes: ______________________________

Adverse consequences on family, work, social relationships:

_____________________________

Medical consequences (injury or disease due to substance use):

_____________________________

Past Medical History:

Trauma history: _____________________________

Surgeries: __________________________________

Hospitalizations: ___________________________

Medical conditions (GI bleed, pancreatitis, anemia, pneumonia, hepatitis B or C, liver cirrhosis, HIV, myopathy, hypertension, sleep apnea, seizures, peripheral neuropathy…):___________________________________________

Medications (prescription & non-prescription):

___________________________________________________________________

Medication allergies: _____________________________________________

Past psychiatric history: _________________________________________

Social History (check all applicable):

  • Violence history
  • Legal problems (DUI, arrests, legal infractions, incarceration, probation)
  • History of having been abused (physical, mental, spousal, or sexual)
  • Work problems (e.g., absenteeism, presenteeism, misconduct, poor performance)
  • Substance-related behavior (e.g., unkempt appearance, involvement in accidents, inappropriately aggressive behavior)
  • Other, please specify: ___________________________

Mental Status Examination (MSE):
In addition to a general MSE, please review substance use related behaviors such as uncooperativeness, defensiveness, evasiveness, odor of alcoholic beverages, drowsiness, slurred speech, agitation, or tremors.

Cognitive Screening Tests:
Brief cognitive screening tests are recommended. The Montreal Cognitive Assessment (MoCA) may be used in identifying potential cognitive impairment among substance use disorder patients. (Using a cut point score of less than 26 the sensitivity for Substance Use Disorder is 83% and specificity is 73%.) In cases where the MoCA score is normal, i.e., 26 and above, but the clinical impression suggests clinical impairment is present; further psychological testing may be indicated.

Physical Examination:
In addition to a general physical examination, please specifically review:

  • Weight & height:
  • Vital signs:
  • HEENT:
  • Head: unexplained trauma signs
  • Eyes: dilated or constricted pupils, red conjunctiva, jaundice
  • Nose: perforated septum, fracture
  • Mouth: dental caries, gingivitis, burns on inside lips
  • Gastro-intestinal: RUQ tenderness, hepato-spenomegaly, Liver stigmata (jaundice, umbilical venous collaterals, ascites, spider angiomas, palmar erythema)
  • Neurological:
    • Cranial nerves
    • Motor
    • Sensory
    • Reflexes
  • Musculoskeletal: unexplained trauma signs or myopathy, and Dupuytren’s contracture.
  • Dermatological:
    • nicotine stains, track marks, bruises, abscesses.

Psychiatric Screening Questionnaires:
Please screen for common psychiatric comorbidities with screening questionnaires such as the PHQ-9 (Patient Health Questionnaire) for Major Depressive Disorder and the GAD-7 for Generalized Anxiety Disorder, and the PCL-5 for Posttraumatic Stress Disorder.

Laboratory:
Please include results of appropriate laboratory investigations that may include a CBC (with MCV), liver enzymes (with GGT), blood borne pathogen (e.g., Hepatitis and HIV) and a drug test (components determined by the agency and/or the SAP).

Review of medical documentation and/or collateral interviews:
Review relevant collateral information or interviews (e.g., co-workers, supervisors or family)

Diagnostic formulation as per DSM-IV-TR:
Does the LEO meet the DSM-IV-TR criteria for a substance use disorder?

  • NO
  • YES (If YES, indicate type)
    • Substance abuse?
    • Substance dependence?
    • Other? (Specify) _______________

In addition, diagnostic formulation as per DSM-5:

Does the LEO meet the DSM-5 criteria for a substance use disorder?

  • NO
  • YES (If YES, indicate type)
    • Substance use disorder (mild)?
    • Substance use disorder (moderate)?
    • Substance use disorder (severe)?

How long has the LEO been completely abstinent (documented abstinence) from:

Alcohol ____________________
Substances _________________

Has early remission been achieved (as per DSM-5 criteria)?

NO
YES (i.e., no longer meeting DSM-5 criteria for at least 3 months)

Coping Skills Evaluation:
Please review current coping mechanism(s) to help prevent relapse:

  • Exercise
  • Sleep
  • Relaxation techniques
  • Social support
  • Avoidance of environmental precipitants and “risky situations”
  • Spiritual factors
  • Hobbies
  • Refusal skills

Treatment Recommendations:
Please include recommendations to assist with continued relapse prevention.

Monitoring Recommendations:
Include type, duration and frequency

Co-morbidity and Long-Term Adverse Conditions:

  • Are there co-morbid psychiatric conditions or suspected conditions? If so, what investigation or treatment is recommended?
  • Are there co-morbid medical conditions or suspected conditions? If so, what investigation or treatment is recommended?

Prognosis and Risk of Relapse:
Please assess the risk of relapse to substance use.

Recommendations for Return to Duties:
Please include your opinion as to whether or not the LEO can return to full duty. If not, can the LEO return to restricted duty, and if so, what restrictions are recommended?

Treating Physician Statement:

Provide additional information not included above that may be helpful to the review by the police physician:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Signature of Physician _____________________________ Date______________

Printed or Typed Name of Physician:

_________________________________________________________________________

Telephone Number______________________________________________________

[1]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%.)

[2]Such as the PHQ-9 (Patient Health Questionnaire) for Major Depressive Disorder and the GAD -7 For Generalized Anxiety Disorder, and the PCL-5 for screening for Posttraumatic Stress Disorder