Name of the Procedure:

Common Name(s): Alcohol and/or Substance Abuse Structured Assessment
Medical Term(s): HCPCS Procedure G0397

Summary

This procedure involves a structured assessment and intervention for individuals abusing alcohol or substances other than tobacco. It includes using standardized tools like the Alcohol Use Disorders Identification Test (AUDIT) or Drug Abuse Screening Test (DAST) to evaluate the level of abuse. Intervention sessions are conducted, lasting more than 30 minutes, to help manage and reduce substance use.

Purpose

Medical Conditions Addressed:

• Alcohol Use Disorder
• Substance Use Disorder (excluding tobacco)

Goals and Expected Outcomes:

• Accurate assessment of substance abuse levels
• Creation of an effective intervention plan
• Reduction of substance use and associated harm
• Improvement in overall health and functionality

Indications

Symptoms or Conditions Warranting the Procedure:

• Signs of alcohol or substance abuse (e.g., withdrawal symptoms, dependency behaviors)
• Frequent intoxication episodes
• Substance-related health issues

Patient Criteria:

• Individuals showing significant substance use without tobacco
• Patients agreeing to participate for a duration of more than 30 minutes

Preparation

Pre-Procedure Instructions:

• No specific fasting or dietary requirements
• Patients may be advised to avoid substance use before the assessment
• An initial screening or recommendation by a healthcare provider

Diagnostic Tests or Assessments Required:

• Basic medical history and substance use history
• Initial screening questionnaires

Procedure Description

1. Initial Assessment:

   • Conducted using structured tools like AUDIT or DAST.
   • Input from patient’s medical and substance use history.

2. Intervention Session:

   • Conducted in a collaborative and non-judgmental manner.
   • Counseling techniques and motivational interviewing.

3. Planning:

   • Developing a personalized intervention strategy.
   • Setting achievable goals for reduction or cessation of substance use.

Tools and Equipment:

• Questionnaires (e.g., AUDIT, DAST)
• Counseling materials

Anesthesia or Sedation:

• Not required.

Duration

Typically lasts more than 30 minutes.

Setting

Outpatient clinic, substance abuse treatment center, or a healthcare provider's office.

Personnel

• Licensed healthcare provider (e.g., physician, psychologist, counselor)
• Trained nurses or substance abuse specialists

Risks and Complications

Common Risks:

• Emotional distress during the assessment
• Disclosure of sensitive information

Rare Risks:

• Negative reactions to confrontation about substance use
• Psychological discomfort

Management of Complications:

• Supportive care
• Referral to mental health professionals if needed

Benefits

Expected Benefits:

• Accurate identification of substance use issues
• Development of a tailored intervention plan
• Reduction in harmful substance use behaviors

Timeframe for Benefits:

• Varies per individual; some may see benefits within weeks, others may take longer.

Recovery

Post-Procedure Care:

• Regular follow-up appointments
• Continued counseling sessions
• Additional assessments to monitor progress

Expected Recovery Time:

• Continuous and typically requires ongoing management.

Restrictions or Follow-Up:

• Avoid substance use post-assessment as much as possible
• Regular self-monitoring and reporting

Alternatives

Other Treatment Options:

• Brief intervention sessions
• Inpatient rehabilitation programs
• Medication-assisted treatment

Pros and Cons of Alternatives:

• Brief interventions: less time-intensive but may be less comprehensive.
• Inpatient rehabilitation: more intensive support but greater time and financial commitment.
• Medication-assisted treatment: effective for certain substances but may introduce new risks or side effects.

Patient Experience

During the Procedure:

• Expect to answer detailed questions about substance use.
• Emotional responses may vary based on personal experiences and substance abuse history.

After the Procedure:

• Possible relief from addressing the issue.
• Continued need for counseling and support.

Pain Management and Comfort Measures:

• Emotional support from healthcare providers.
• Opportunity to discuss concerns and feelings during sessions.