Recovery Options: The Complete Guide

Introduction

My husband is spending too much money on cocaine. How can I get him to stop?

I think I might be drinking more than I should, but I don’t like AA. Is there another program that might work for me?

I think my teenage daughter is smoking pot Should I try to get her into a residential drug program? If so, how do I know which one is the best?

I started using heroin, and now I can’t stop. I’m scared of treatment. What can I do?

We wrote this book to answer these questions—to assist those in need of help with alcohol and other drug problems to find not just the kind of care that medical or self-proclaimed experts think is right for everyone, but the type of treatment that best suits a particular person. Remarkable progress in understanding the behavioral and biological causes of addiction has challenged our fundamental assumptions about what addiction is and what the best treatments for it are. There are many more options today than ever before. To take advantage of them, you or your loved one doesn’t even need to be ready to give up alcohol or other drugs or to know whether there is a real problem bad enough to require help.

Unfortunately, while research knowledge of what works and what doesn’t has grown tremendously, this information has been very slow to reach treatment providers and to affect the care they offer. In fact, many providers deliberately resist change because, they claim, I know what worked for me, and I’m sure that it can work for everyone willing to do as I say. This attitude has stymied progress in the field and has prevented advances from being available to as many people as they should be. We hope that this book can help people seek the type of care they’ve decided makes sense for them—and, perhaps, consumer choices will push for change among those who believe that one size fits all.

I (Joe) am often asked why I have spent the past 25 years of my life trying to understand addiction and how to find the best treatment for it. Contrary to most people’s expectations, I have never had a problem with alcohol or other drugs, and no one in my immediate family has an addiction problem. Rather, I first became interested in addiction while a medical student after I received a rather dramatic wake-up call from a Vietnam veteran I treated.

I was working in the emergency room late one evening. A man who looked much older than his 40 years was coughing up blood. After a careful history and physical, I diagnosed his problem as esophageal varices secondary to portal hypertension. Essentially, he had a failing liver, and his swollen fragile blood vessels were tearing. That, along with a deficiency in his blood-clotting system, had caused severe blood loss. I ordered a blood transfusion, and when an endoscopy confirmed my diagnosis, I felt quite satisfied with myself. Knowing that his problem was probably related to drinking, I discharged him when he was medically stable and told him to stop drinking. I even went so far as to get a list of local AA meetings for him. I quite proudly presented this case to my attending doctor the next morning and received a pat on the back for a nice job in diagnosing and treating the patient.

Two weeks later, the same man was back in the emergency room coughing blood and complaining that he’d been thrown out of his apartment. He said he was experiencing daily nightmares and that he needed to drink to knock himself out at night. Not surprisingly, his continued drinking had aggravated his medical condition. His eyes were yellowish, and his abdomen was filled with fluid. This time, I admitted him to the hospital and began a medical-detoxification program. On the second day, while on rounds with the attending doctor, several other medical students, an intern, and a junior resident, I presented this interesting case. Hold out your hands, I ordered, Let’s see how those tremors are doing today. He looked up at me frightened, complaining of spiders crawling up his legs. He then shouted, Doc, I need your help, and held out his hands. As I reached out to his left hand to test for a tremor, he punched me square on the jaw with his right.

After that stunning experience, I developed a healthy respect for the problems associated with addiction. In my arrogance, I had failed to respond this man’s pain or his core problem: He wouldn’t be able to stop drinking and improve his liver problems unless the posttraumatic stress disorder that was driving his nightmares was also addressed. While many of my colleagues have become angry at patients like the vet, who repeatedly show up drunk in the emergency room, seemingly unwilling to take the good advice the doctors offer, I have found the problem to be an interesting challenge. That man, in the midst of his DTs (delirium tremens) understood more about addiction than did any of the writers of my textbooks. He showed me very literally that addiction hurts not only the person who suffers it but the people around him, as well.

I began to ask about addiction problems among my patients, and another homeless man, named Jim, became my best teacher. While I have been blessed by wonderful mentors, it was my conversations with Jim that most shaped my thinking about addiction. Perhaps the most important lesson was seeing his transformation as he sobered up. Not only did his physical problems improve, but he also seemed to undergo a fundamental healing in his relationships with his family and with himself. I had seen the remarkable effects of heart transplants and the wonder of childbirth, but watching this man’s transformation during his recovery was unlike anything else I had ever seen in medicine. With many medical and psychiatric problems, improvement is gradual and often incomplete. Jim’s turnaround, however, was dramatic.

I dedicated myself to finding out why this intelligent, good man who cared about his family and society had come to a point in his life where nothing had mattered to him but the next drink. I wanted to know, too, what could help others like him achieve the remarkable recovery Jim had.

During my years in medical school, I also earned a Ph.D. in psychology. I studied animal models of addiction. From my basic research, I learned how stress can make animals drink more alcohol—and how certain drugs, such as naltrexone, can prevent this response. During my residency in psychiatry, I learned more about various treatment options, including cognitive-behavioral therapy and medications such as methadone for drug addiction. Also, while completing my postgraduate fellowship in addiction, I began a clinical trial of naltrexone to treat alcoholism in humans at the Philadelphia VA Medical Center. This research resulted in the discovery of the first new medication approved for alcoholism treatment by the U.S. Food and Drug Administration (FDA) in the past 50 years—and it can cut the risk of relapse by 50% among those who take it.

Why do only a tiny minority of treatment centers offer this drug to their patients, and why haven’t we heard more about it? Unfortunately, several factors are involved. A moralistic assumption that addiction is a personal choice seems to underlie most of our treatment for alcohol and other drug problems —even in rehab centers run by people who say they believe that addiction is a disease requiring medical care. One day, while driving to work, I saw a bumper sticker with the Nancy Reagan antidrug motto, Just Say No, on it. Thinking about the prevalence and belief in the utility of that simple slogan, I realized one reason why it was so hard for treatment providers to begin utilizing the new medication.

If you assume that addiction is a matter of self-control summed up by the Just Say No slogan, then there must be a moral, characterological, or spiritual weakness in people who abuse drugs. If this is the case, then measures such as imprisoning them for years, taking their property, and condemning them in prevention campaigns such as the users are losers TV spot, make sense. Giving alcoholics and other addicts drugs to ease their craving or withdrawal is not helpful from this perspective. Even if the medications themselves cannot be abused, it is seen as cheating because it makes the hard task of overcoming one’s weaknesses easier.

For me, however, this view of addicts as weak and deserving of pain and punishment did not square with what I knew about the many remarkable people I had met who had become alcoholics or other kinds of addicts. They were successful businesspeople, loving fathers and mothers, bright college kids, and many plain ordinary, decent people like Jim, who had just happened to develop a problem with alcohol or other drugs. As they recovered, they were reborn and returned to their formerly positive and productive lives. From my observations working with addicts and from clinical and basic research, it was clear that addiction was not a choice. Instead, the interactions among the drug, the person’s life experiences, and the person’s brain caused the problem —not some character flaw or moral weakness.

Perhaps nowhere in all of medicine is there a bigger gulf between clinical practice and clinical research than in the field of addiction. Alan Leshner, the Director of the National Institute of Drug Abuse, speaks of the great divide between research and treatment practice. Misperceptions about how people become addicted and how to free people from addiction permeate public policy, the news media, and public opinion. I decided that if my research was ever to reach the alcoholics who could benefit from it, I would have to help bridge the gap between what we think we know about addiction and effective treatment, and what addiction actually is and what actually works to treat it.

In order to get a sense of what people who were treating addicts in the community were thinking, I joined an Internet mailing list consisting of a wide cross-section of people interested in the issue. It was there that I met my coauthor, Maia Szalavitz. The mailing list, supposedly devoted to academic and scholarly discussion of addiction-related topics, was, in reality, a battlefield. People who held varying notions about alcohol and other drug problems came to joust with others over the superiority of various positions. There were recovering alcoholics and other addicts who believed in 12-step programs, academics who thought cognitive and behavioral approaches were the only way to deal with substance misuse, people who believed alcoholism didn’t exist and that all alcoholics can learn to control their drinking, and even a Freudian psychoanalyst. Few were willing to acknowledge that some people would benefit from an approach other than their own —and few could see that this narrow-mindedness might hurt some of those they so sought to help. The only thing the group seemed to have in common was that none of the treatment professionals offered naltrexone as an option.

Maia came to the list as a journalist who was also an ex-addict. Her position was, if it helps people, do it, and over time, she became increasingly convinced that those who needed help weren’t getting the benefits of treatment advances. The list showed that many longtime drug counselors weren’t even aware that research had found their basic beliefs about addiction to be wrong and their practice to be harmful. Despite contrary evidence, they continued to force people to accept the one method they believed was the only possible road to recovery.

In any other field, a discovery like ours, which has been hailed as one of the most important recent contributions to addiction treatment, would be picked up and used by most professionals once it was published. The scientific community recognizes its importance —I was recently awarded the Joel Elkes International Award in Psychopharmacology. The addiction-treatment community, however, is particularly resistant to change.

As a researcher, I have long been frustrated by the alcoholism and addiction field’s reliance on miracle cures and horror stories, rather than on science, to guide patient care. After all, most Americans with diabetes or even an emotional problem such as depression wouldn’t accept being told by a doctor that praying and turning your will and life over to the care of God as you understand Him, as AA suggests, is the only treatment for their illness. Why shouldn’t alcoholics and other addicts get research-based medicine the way people do for any other disease? While AA and the other 12-step groups have certainly worked well for many, the medical profession has not best served patients or even 12-step programs by claiming that they are the only valid method of recovery.

Both Maia and I came to the conclusion that to get the best care, patients themselves need to know what to look for—because many professionals have too much of an attachment to their own ideas of what should work to take into account individual differences. As a result, we decided to collaborate on this book. There is no other book like it—all the previous popular accounts of substance-abuse treatment have been focused mainly on helping patients accept one particular approach to care, rather than informing them about the debates in the field and letting them make up their own minds. All of them tend to be vague in their accounts of what actually takes place in treatment—for fear of scaring people off.

We respect your intelligence more than that. We know that if you are seeking help for yourself or for a friend or loved one, you want clear, concise information to guide you through a very difficult time. We know that most people would rather be informed than left to wonder what the jargon being thrown at them really means. We also know that people are looking for alternatives now in particular. Some have found the AA one true way to be unhelpful to them. They have tired of being told that they need to leave their critical-thinking skills behind if they are to recover, and that their families are complicit codependents who have an intersecting disease. They want to know more about getting better than is offered by people whose only knowledge of addiction has been gained from personal experience. While personal experience is crucial to understanding addiction, it’s not the only valid source of wisdom. You wouldn’t listen only to people who had undergone heart transplants while ignoring what the doctors who treated them said and refusing to look at medical research showing the probability of success in particular types of cases. A person considering treatment should want to know about it from all angles. We hope to put all the conflicting perspectives on alcoholism and other forms of addiction in context.

The good news is that there is effective treatment for alcohol and other drug problems, and the odds are in your favor that if you are seeking help, you will recover. We want to show you how—without sugar-coating the truth or hiding what treatment is really like. We want to demystify treatment so that you know what to expect, what you want for your own recovery, and what is appropriate and inappropriate care.

Our book is divided into three parts. In the first section, The Problem and the Search for Solutions, we explore what addiction is—and what it isn’t. We look at how drugs work, what their real dangers are, and how the dangers can be minimized so that alcoholics and other addicts are as healthy as possible when they are ready to recover. We also examine why some people are particularly prone to alcoholism and other forms of addiction and the genetic and learning mechanisms that help create these conditions.

The remainder of this part provides an introduction to the various types of treatment and the ideas on which they are based. It discusses how effective treatment succeeds —and which types of treatment are not effective. For loved ones and families, it lays out the stages of change that people go through in their recoveries and tells how to help people move through them and get what they need to progress in each phase. We also provide tips for people with drug problems, to help reduce their fear and motivate them to change. Finally, this section offers a guide to choosing treatment—and questions to ask to find the best treatment facility once you have decided on the most suitable treatment type.

The second part, The Options, provides more detailed information about each kind of treatment—including our treatment system at the University of Pennsylvania, Alcoholics Anonymous and other self-help groups, moderation programs, methadone, and various kinds of residential treatment. We examine medications used to detoxify from alcohol and other drugs and to fight cravings. Each chapter includes stories of patients’ experiences with recovery by each method—both positive and negative, wherever possible. There is also a special chapter on treatment for teenagers and a chapter on alternative treatment. Each chapter also summarizes the research on the treatment type it covers and includes specific things to look for which exemplify the best care in that particular treatment.

Part Three, Life after Treatment, contains the information you need to help stay clean and sober and to prevent relapse—and to minimize any damage caused by slips that do occur. It provides suggestions for dealing with the emotional difficulties that can arise at the start of recovery, as well as information on what to do if these prove to be clinical conditions such as depression, anxiety disorders, or posttraumatic stress disorders.

Throughout the book, you will find sidebars with special information for loved ones and family members—and some that highlight particular points for people with drug problems themselves. There are diagnostic tests, and other summaries and tips to underscore important information.

The people who have shared their stories here are real—though their names have been changed to pseudonyms. In the rare instances where we use composites to illustrate particular points, their names appear italicized at first mention.

Readers of this book shouldn’t have to blindly fumble their way into treatment, the way Maia did when she needed help. They’ll know the lingo, they’ll know the theories, and they’ll know what outcomes research has found about particular approaches with particular people. They’ll have heard from people who have been there —and learned from their experiences and mistakes. In rehab, even more than in clothes shopping, an educated consumer is the best customer.

PART ONE

The Problem and the Search for Solutions

CHAPTER 1

Understanding Problems with Alcohol and Other Drugs

Noah, a man of the soil, proceeded to plant a vineyard. When he drank some of its wine, he became drunk and lay uncovered inside his tent. Ham, the father of Canaan, saw his father’s nakedness and told his two brothers outside. But Shem and Japheth took a garment and laid it across their shoulders; then they walked in backward and covered their father’s nakedness. Their faces were turned so they would not see their father’s nakedness.

Genesis 9:20

Psychoactive substances have fascinated, befuddled, bewitched, and terrified humanity since time immemorial. Some anthropologists (no, not just those found on barstools!) reckon that the invention of beer-making processes was a crucial step in the progress of civilization. Desire for beer may have spurred early tribes to settle down and farm its ingredients. Throughout much of history, alcoholic beverages were the primary source of fluids for city dwellers because water was too contaminated to drink, and alcohol kills many microorganisms. In fact drug use predates human history. Many animal species seek out intoxicating plants and happily consume fermented grain.

We know of no human culture that does not make use of psychoactive drugs —often in a way central to their religious and celebratory rituals. Even the Chukchee, Siberian tribespeople who live in the most hostile Northern regions, rooted out a mushroom with intoxicating properties and learned further (one hates to speculate on how), that these properties were greatly magnified if you ingested the urine of those who ate the mushroom. Urine is few people’s first choice as an intoxicating beverage, but with few other available agents to alter consciousness, drinking it became part of Chukchee culture.

It is often hard to admit that there is anything positive about drug use when you are addicted and want to quit or are dealing with an alcoholic or other addict whose life is being ruined by it. Also, most books on treatment and recovery don’t mention anything good at all about substance use, for fear of encouraging it. However, it’s crucial to learn why these substances are attractive if you want to understand addiction and recover from it. To understand maladaptive drug use, you first need to recognize that use itself is not always wrong or harmful, despite attempts by various factions to convince us otherwise.

It’s also important to recognize that the vast majority of drinkers and other drug users —including those who try heroin and cocaine —never become addicted or even suffer short-term drug problems. Just 5% of marijuana users take the drug daily on a long-term basis, and only 10–20% of those who try alcohol, heroin, or cocaine suffer the problems that would define them as abusers—an even smaller proportion of these abusers can be labeled addicts or alcoholics. The only drug that hooks the vast majority of its regular users is nicotine.

These observations suggest very strongly that pharmacology alone cannot explain drug problems—because if it did, most drugs should hook most people. To understand and recover from addiction, you need to understand not only how drugs affect the brain in general, but also what is different about those who can take it or leave it, and those who try and fail in their efforts to stop.

Am I an Alcoholic or an Addict?

You would think that there would be an easy answer to the question Am I addicted to alcohol or other drugs? which plagues substance users and their loved ones. However, defining and diagnosing alcoholism and other forms of addiction is harder than it sounds. Some examples can illustrate why.

Robert is a 29-year-old website designer. He smokes pot daily—on weekends, four to five joints. His work has been praised by his clients, but he has also lost business because he missed deadlines. His fiancee recently broke their engagement because she felt he wasn’t really there for her—and that his use was out of hand. He feels that she was just too demanding. He has a 3-year-old son from a previous relationship, and while his former partner does not approve of his lifestyle, she admits that he is wonderful with the boy and never skimps on child support.

Janet is a 47-year-old programmer and mother of two, who suffers from chronic pain due to injuries sustained in a car accident. She has tried everything—from aspirin to electrical stimulation. Nothing has helped but large doses of opiates. Fearing addiction, she weaned herself from the drugs, but after undergoing withdrawal, she was unable to function because of her pain. Two months later, she was doing little more than lying in bed, putting her job in jeopardy and minimizing her ability to care for her kids. When her doctor insisted she begin taking opiates again, she stuck to her prescribed (although large) doses, and her husband, kids, and boss all support her contention that she is happier, healthier, and more productive now.

Chris is a 32-year-old drinker. He drinks almost nonstop from Friday evening through Sunday night. Though most of his drinking is restricted to weekends, he has been missing work on Mondays due to hangovers. His girlfriend is concerned. She says she doesn’t like how he acts when he is drunk. When she convinces him to take a weekend off, he mopes and can speak of nothing but how she’s a killjoy and that there’s nothing wrong with hoisting a few.

Virginia, 41, snorts cocaine twice a year as a celebration. She usually stays up all night and generally consumes about a quarter of a gram. She only uses on New Year’s Eve and her birthday and has maintained this pattern since attending college 20 years ago. While in school, she used coke twice a month but cut back when she found that she didn’t like the way she felt afterward. She drinks wine with dinner. She also smokes an occasional joint and has taken Ecstasy (MDMA, a popular club drug). Her drinking and other drug use have never interfered with her work, and she believes they are a meaningful part of her social life, to be enjoyed and savored.

Is Janet an addict? What about Robert and Virginia? Is Chris an alcoholic? Simply looking at how much or how often each of them consumes their substance does not tell the whole story. Chris drinks less often than Janet takes her drugs—and he doesn’t undergo severe withdrawal symptoms after a binge. Many would argue, however, that despite the fact that Janet is a daily user and is physically dependent on opiates (when she stops taking them, she becomes sick), she shows none of the important signs of addiction. She is not obsessed with drugs, she takes them as prescribed, and her life is improved, not diminished, by them. Meanwhile, Chris, who doesn’t drink every day, is experiencing problems as a result of his alcohol consumption, and his life is dominated by thoughts of when he can next indulge. While Robert uses every day, the consequences of his pot smoking are not as clear cut—he might be losing out because he smokes too much, or he might just have a slacker personality. Virginia, however, has not experienced any problems as a result of her drug use.

Many who studied addiction, in search of a way to quantify the problem, often missed much of its essence as a result. Physical addiction (or dependence, as it is properly called) was seen as more important than psychological addiction because it could be measured and was visible. As a result, cocaine was seen as nonaddictive as late as the 1980s—because it didn’t produce the dramatic illness seen in withdrawing heroin addicts. In 1982, Scientific American went so far as to compare coke addiction with the desire for more potato chips.

For most people, however, the psychological aspects of addiction —the impaired ability to control the use of the drug, the craving, the depression as it wears off, the life consequences—are far more important than the physical withdrawal symptoms or how often the drug is actually used. People taking painkillers to treat pain due to burns or other painful conditions often withdraw from drugs stronger than heroin with no more discomfort than people suffering the flu —it’s only when your psychological comfort and emotional well-being depend on access to a drug that heroin withdrawal becomes hell. If you don’t need to have pain killed, you probably won’t want painkillers for long, basically. Rather than being trivial then, the mental state of the addict is crucial to understanding addiction. Also, increasing knowledge of how the brain works shows that the psychological is physical, and vice versa—because all our thoughts, desires, dreams, and fears must be encoded somehow.

Modern definitions of drug problems try to take all of this into account. The most widely used scheme for defining substance problems is found in the American Psychiatric Association’s Diagnostic and Statistical Manual. There are two levels of drug problems that can be diagnosed: abuse and dependence.

When Is It a Problem?

The essence of these definitions is that a substance abuser has experienced some level of problems related to his or her use of psychoactive substances, but he or she does not have either the major difficulty stopping or cutting down, or the long-term entrenched problems that an addict does. A substance abuser may be headed for substance dependence, but the vast majority (research estimates about three out of four) are able to outgrow their problems, with little or no assistance, usually by their mid to late 20s. This finding has obvious implications for dealing with teen drug problems, but, unfortunately, because the line between abuse and dependence is so fuzzy, it’s almost impossible to predict who will mature out of the problem naturally and who will need help.

Don’t worry too much about whether you or your loved one is really an addict or just abusing. What’s important is to realize that use has started to become problematic and to recognize and understand the nature of the process that can occur if control over using continues to lapse.

Diagnostic Criteria for Substance Dependence and Substance Abuse

Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1) tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect

(b) markedly diminished effect with continued use of the same amount of the substance

(2) withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(3) the substance is often taken in larger amounts over a longer period than was intended

(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use

(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6) important social, occupational, or recreational activities are given up or reduced because of substance use

(7) the substance use is continued despite knowledge of having persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significan impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Addiction

Addiction begins when someone has extreme difficulty controlling, cutting down, or stopping drug use despite repeated negative consequences related to it. Note that this definition does not require physical dependence and that physical dependence doesn’t always mean addiction. Here, Janet is not an addict because her use of painkillers is helpful and productive, not harmful. Although some alcoholics and other addicts may claim that their use is a positive thing, if they do have a problem, they will probably not, unlike Janet, be supported in continued drug taking by their family, their workplace, and their doctors! Chris, however, may well be an alcoholic or on his way to becoming one, and Robert, too, has at least a substance-abuse problem and quite possibly an addiction to marijuana, although some may argue that he may simply prefer a slacker lifestyle to achievement. Virginia, however, meets no criteria for drug abuse or dependence and, aside from the fact that some of the substances she takes are illegal, would be considered by most to be simply a recreational, controlled user.

How can you tell where your own drinking or other drug use fits in and what steps you should take to deal with it? Here are some screening tests for alcohol and other drug problems. They can help you determine whether you should see a professional to further assess the problem.

CAGE Screening Test

C Have you ever felt the need to cut down on your drinking? [drug use]

A Have you ever felt annoyed by someone criticizing your drinking? [drug taking]

G Have you ever felt bad or guilty about your drinking? [drug use]

E Have you ever had a drink first thing in the morning to steady your nerves and get rid of a hangover? (eye-opener) [or a drug to relieve withdrawal]

If you answered yes to one or more of these questions, you may have a problem and should consider getting help. As you will see later, a complete assessment to determine the level of severity of the substance problem and to diagnose any other problems that may be driving it is an important first step. To further examine the nature and seriousness of your problem, you may also want to try a second screening test. The first of the following three tests covers alcohol use, the second other kinds of drug use, and the third specifically addresses cocaine use.

Alcohol Use Disorders Identification Test (Audit)

Record the total score. Eight or higher means you should get a professional evaluation.

Source: World Health Organization (WHO), 1987.

Substance Use Disorders Test

Record the total specific items. If you score higher than seven, you should get a further evaluation because you may have a substance-abuse problem.

Source: Adapted from WHO, AUDIT.