A substance abuse evaluation (SAE), often called a drug and alcohol assessment, is a structured process conducted by a trained professional to determine an individual’s relationship with psychoactive substances. The purpose of this assessment is to investigate whether a Substance Use Disorder (SUD) is present and to gauge its severity. This specialized interview and data review collects comprehensive information about a person’s history and current patterns of use. The findings guide the most appropriate next steps, which may involve a personalized treatment plan or serve as documentation for legal or employment compliance.
Preparation and Initial Logistics
The evaluation is conducted by licensed mental health professionals with specialized training in addiction assessment and treatment. Assessors often include licensed clinical social workers, certified substance abuse counselors, psychologists, or licensed professional counselors. The evaluation typically takes place in an outpatient clinic, private practice, or virtually.
Individuals may seek an evaluation voluntarily or be mandated to participate. Mandated evaluations are frequently required by the court system, such as following a Driving Under the Influence (DUI) charge, or as a requirement from an employer or school. To prepare, the individual should gather necessary documentation, including identification, court-ordered paperwork, and relevant medical history.
Before the assessment begins, the professional ensures the individual understands the limits of confidentiality and the informed consent process. The client must authorize the evaluator to share the final report with any referral source, such as a court or attorney, especially in mandated cases. This groundwork establishes the boundaries and expectations for the information-gathering process.
Core Assessment Components
The central part of the evaluation is a thorough clinical interview, which can last up to a couple of hours. The professional systematically gathers a history of substance use, including the age of first use, substances consumed, and typical frequency and duration of use. Attention is paid to the consequences the use has caused across various life domains, such as occupational issues, relationship strains, or physical health problems.
Standardized screening tools are often administered alongside the interview to provide an objective measure of risk. These validated questionnaires help flag problematic substance use behaviors. Examples include the Alcohol Use Disorders Identification Test (AUDIT) or the Drug Abuse Screening Test (DAST), which assess the severity of risk and symptom endorsement.
The evaluator may also seek collateral information to create a more complete picture of the individual’s situation. With the client’s explicit authorization, this information may be gathered from family members, employers, or existing medical and psychiatric records. In some cases, laboratory toxicology testing, such as a drug test, may be part of the assessment to verify recent substance use.
Diagnostic Criteria and Formulation
The collected data—the interview narrative, screening tool scores, and collateral information—is synthesized into a formal clinical formulation. The professional uses established criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to determine if a Substance Use Disorder (SUD) exists. The DSM-5 outlines eleven specific symptoms, ranging from craving and tolerance to continued use despite negative consequences.
The number of symptoms endorsed determines the level of severity for the SUD. Endorsing two or three symptoms indicates a mild SUD, while four or five symptoms indicate a moderate disorder. A severe SUD is indicated when six or more of the eleven criteria are met, signifying a greater need for intensive intervention.
Recommendations and Follow-Up
The final stage involves creating a comprehensive written report detailing the findings and the resulting action plan. This report summarizes the individual’s history, the clinical determination, and specific recommendations for treatment or education. The report is delivered to the client and any authorized third parties, such as the court or the referring entity.
The recommendations are tailored to the individual’s needs and the severity of the determined disorder. The professional utilizes placement criteria, such as those established by the American Society of Addiction Medicine (ASAM), to match the client with the appropriate level of care. Options range from no further action, to brief educational interventions, or individual outpatient counseling.
For moderate or severe disorders, recommendations often include a more intensive level of care, such as an Intensive Outpatient Program (IOP) or residential treatment. The goal is to recommend the least restrictive yet most effective intervention necessary to address substance use issues and support behavioral change. The evaluation provides a clinical roadmap for the individual’s journey toward recovery or compliance.