Evaluating Substance Abuse in Forensic Settings: Tools and Techniques

Substance abuse refers to the excessive use of psychoactive drugs, including alcohol, marijuana, heroin, cocaine, and other illegal substances. The misuse of these drugs can result in significant physical, social, and emotional harm to individuals. In forensic settings, people with mental illnesses frequently exhibit high rates of substance use disorders. Historically, those who engaged in substance abuse were often labelled as sociopaths. In 1952, the first edition of the Diagnostic and Statistical Manual (DSM-I) classified alcoholism and drug dependency as subsets of sociopathic personality disturbance. People diagnosed with substance use disorders were considered threats to society. In recent times, it has been recognized that the relationship between substance abuse and sociopathy is not that simple and is far more complex than what was initially suggested by the DSM-I.

Illicit Drugs: Types and Effects

Nevertheless, studies have shown a strong association between substance abuse and criminal behaviour. For example, individuals who commit violent crimes are often found to be under the influence of drugs more frequently than those who commit non-violent offences. From a legal point of view, two main aspects need to be considered regarding the connection between substance use and criminal behaviour-

1. The illegal activities involving drugs, such as their possession, sale, and use
2. The antisocial behaviours that arise due to the influence of drugs.

The kind of criminal behaviour associated with substance abuse varies greatly depending on the kind of specific drug involved. For example, heroin is strongly associated with money-producing crimes. Many cocaine or crack users tend to use multiple substances along with cocaine. These individuals often have a long history of previous drug use and involvement in drug sales. They are also more likely to engage in criminal activities that generate income outside of drug-related activities. Alcohol, one of the most commonly and widely abused substances, has been found to have strong associations with violent crimes. Alcohol and other drugs have been addressed in both criminal and civil laws. According to the data from the National Institute of Justice, more than 60% of the individuals who were taken into the criminal justice system tested positive for some or the other drug at the time of their arrest.

Drug-related Glossary

Thus, it is important to assess these substance use disorders in the forensic population to provide them with better rehabilitation strategies. Assessment plays a very important role within the criminal justice system. Forensic data and expert opinions are often sought to determine whether an individual was under the influence of substances during an alleged crime. It is also helpful in assessing whether they have a substance dependency and evaluating the potential for successful treatment. These assessments can also influence arguments about whether substance use or dependence should mitigate guilt. Following a determination of guilt, assessments may further inform decisions about the individual’s suitability for treatment or rehabilitation. In legal contexts, substance use assessments lead to critical and immediate decisions. The objectives for these assessments include-

1. General screening to check the presence or absence of substance use
2. Comprehensive evaluations that facilitate diagnosis and understanding of the severity of any identified issues
3. Tools that suggest treatment strategies and ways to prevent relapse
4. Extensive assessments that consider the individual’s functioning across various aspects of life.

Moreover, in forensic settings, these assessments serve to inform decisions that could help in safeguarding the community.

Some of the common methods employed in the assessment of forensic and general populations include behavioral observation, laboratory tests, input from collateral sources, neurological examinations, and self-report measures such as structured interviews. Each category of assessment serves a specific purpose: behavioural observations provide insights into immediate actions and responses; laboratory tests offer objective evidence of recent substance use; collateral informants contribute information from external perspectives; neurological examinations assess cognitive and physical functioning; and self-report measures gather subjective data directly from the individual.

Some of the self-report screening instruments are as follows-

1. Alcohol Use Disorders Identification Test (AUDIT)– The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item scale that can be administered in about two minutes. The primary aim of this scale is to identify individuals with problematic drinking patterns. This test is also helpful in identifying the health hazards related to substance abuse. The AUDIT test covers three main areas-
   1. Patterns of alcohol consumption
   2. Symptoms of dependence
   3. The extent to which alcohol use disrupts daily activities.

These categories match the definitions of alcohol dependence and use in the International Classification of Diseases, 10th Edition (ICD-10), published by the World Health Organization (WHO) in 1992. Originally meant for general medical settings, the AUDIT has also been found useful in prisons. This test is available in several languages, including English, Japanese, Spanish, Norwegian, and Romanian.

2. The CAGE Questionnaire- The CAGE t is a brief four-question instrument that focuses on “cut down,” “annoyed,” “guilt,” and “eye-opener.” It typically takes less than one minute to administer. According to several researchers, the CAGE questionnaire can correctly identify 74% of alcoholics with two “yes” responses and accurately exclude 96% of non-alcoholics. The CAGE is easy to adapt for drug use screening.
3. Michigan Alcoholism Screening Test (MAST)—The Michigan Alcoholism Screening Test (MAST) consists of 22 questions and can be administered in less than seven minutes. Similar to the CAGE questionnaire, it helps differentiate alcoholics from non-alcoholics when there is no motivation to hide substance use.
4. Substance Abuse Subtle Screening Inventory (SASSI)– The Substance Abuse Subtle Screening Inventory (SASSI) test is frequently used in alcohol treatment agencies. The SASSI effectively identifies early-stage substance abuse in individuals who may be in denial. The SASSI-2, an updated version from 1994, includes 62 true-false items. Several researchers found that the SASSI-2 correlates moderately with other screening tools like the CAGE, the MacAndrew Scale, and the MAST.
5. Addiction Severity Index (ASI)- The Addiction Severity Index (ASI) is a standardized structured interview that is widely used for substance use assessment. It evaluates both alcohol and drug use across multiple life areas that may contribute to or be affected by substance use. This interview takes 40-60 minutes. It divides scores into six domains:
   1. Medical
   2. Employment/Financial
   3. drug/alcohol use
   4. Legal/Criminal justice involvement
   5. Family/Social
   6. Psychological/psychiatric.

The ASI requires computer scoring that reflects both current and past functioning across these domains. The ASI is also applicable to incarcerated populations.

6. Time Line Follow Back (TLFB)- The Time Line Follow Back (TLFB) procedure is an interview that was designed to help individuals accurately recall their drinking behaviour over the past twelve months. The interviewer uses a structured hierarchy of questions and a calendar to help clients identify significant events (such as holidays) and periods of high substance use. This method helps in the identification of substance use patterns. These could include times when someone wasn’t using and also the times when they were using those particular substances a lot. This test gives a detailed and accurate report of substance use by the individual.

These different tools and techniques are important for evaluating substance use disorders. Each tool has its own strengths and is useful in different settings, such as general medical environments, psychiatric contexts, and forensic populations.

References

1. Gifford, E. V., Kohlenberg, B. S., Piasecki, M. M., & Webber, E. J. (2004). The forensic assessment of substance abuse. In W. T. O’Donohue & E. R. Levensky (Eds.), Handbook of Forensic Psychology: Resource for Mental Health and Legal Professionals (pp. 315–345). Elsevier Science. https://doi.org/10.1016/B978-012524196-0/50016-4
2. https://www.anewhoperecovery.com/assessments/
3. https://jflowershealth.com/substance-use-disorder-evaluation/
4. Marquant T, Van Nuffel M, Sabbe B, Goethals K. Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review. Front Psychiatry. 2021 Dec 7;12:777141. doi: 10.3389/fpsyt.2021.777141. PMID: 34950071; PMCID: PMC8688775.