Screening instruments for Substance use disorders

Sam Jose
Nursing Tutor
AIIMS Bhubaneswar
nurs_sam@aiimsbhubaneswar.edu.in

 ASSESSMENT OFALCOHOL USE
1.AUDIT (Alcohol Use Disorders Identification
Test)
The Alcohol Use Disorders Identification Test
(AUDIT) is a 10-item screening tool developed by
the World Health Organization (WHO) to assess
alcohol consumption, drinking behaviors, and
alcohol-related problems. Both a clinician-
administered version and a self-report version of
the AUDIT are provided. Patients should be
encouraged to answer the AUDIT questions in
terms of standard drinks.

 A chart illustrating the approximate number of
standard drinks in different alcohol beverages
is included for reference . A score of 8 or more
is considered to indicate hazardous or harmful
alcohol use. The AUDIT has been validated
across genders and in a wide range of
racial/ethnic groups and is well suited for use
in primary care settings. Detailed guidelines
about use of the AUDIT have been published
by the WHO and are available online:

2.MAST (Michigan Alcoholism Screening
Test)
The MAST Test is a simple, self scoring test
that helps assess if you have a drinking
problem. Please answer YES or NO to the
following questions.
24 item screening instrument designed to
identify and access alcohol abuse and
dependence. Shortened 13 item and 10 item
versions are available.

3.CAGE
CAGE” is an acronym formed from the italicized
words in the questionnaire (cut-annoyed-guilty-
eye). The CAGE is a simple screening
questionnaire to id potential problems with
alcohol. Two “yes” responses is considered
positive for males; one “yes” is considered positive
for females.
4 item screening instrument. Particularly useful in
geriatric population and can be easily used in
primary health settings.

3.T-ACE
T-ACE is a measurement tool of four questions
that are significant identifiers of risk drinking
(i.e., alcohol intake sufficient to potentially
damage the embryo/fetus). The T-ACE is
completed at intake. The T-ACE score has a
range of 0-5. The value of each answer to the
four questions is totalled to determine the final
T-ACE score.

 A total score of 2 or greater indicates potential
risk for the purposes of Pregnancy Outreach
Program identification of prenatal risk.

4.TWEAK
TWEAK is a five-item scale developed originally
to screen for risk drinking during pregnancy. It is
an acronym for the questions below.
T—Tolerance*—“How many drinks can you
hold?”
W—Worried—“Have close friends or relatives
worried or complained about your drinking in the
past year?”
E—Eye-opener—“Do you sometimes take a drink
in the morning when you first get up?”

 A—Amnesia—stands for blackouts—“Has a
friend or family member ever told you about
things you said or did while you were drinking
that you could not remember?”
 K—K/Cut Down—“Do you sometimes feel the
need to cut down on your drinking?”
 The TWEAK has been used to screen for
periconceptional risk drinking among obstetric
outpatients

5.SADQ – C (Severity of Alcohol Dependence
Questionnaire)
The Severity of Alcohol Dependence
Questionnaire was developed by the Addiction
Research Unit at the Maudsley Hospital. 20
item scale designed to measure severity of
alcohol dependence. Has five subscales.

 The SADQ questions cover the following
aspects of dependency syndrome:
 physical withdrawal symptoms
 affective withdrawal symptoms
 relief drinking
 frequency of alcohol consumption
 speed of onset of withdrawal symptoms.

6.SADD (Short Alcohol Dependence Data
Questionnaire)
The scale is aimed at the general adult
substance-abusing population, focusing
primarily on those who are mildly to
moderately dependent.
15 item self report questionnaire used to
measure the severity of alcohol dependence.
The SADD questionnaire was derived from the
Alcohol Dependence Data (ADD)
questionnaire.

 The SADD was designed to be
(i) suitable for patients seeking help with a
drinking problem;
(ii) a measure of present state dependence;
(iii) sensitive across the full range of
dependence;
(iv) sensitive to change over time; and
(v) relatively free of sociocultural influence”

7.ADS (Alcohol Dependence Scale)
The ADS provides a quantitative measure of
the severity of alcohol dependence consistent
with the concept of the alcohol dependence
syndrome.
The 25 items cover alcohol withdrawal
symptoms, impaired control over drinking,
awareness of a compulsion to drink, increased
tolerance to alcohol, and salience of drink-
seeking behavior.

8.ASI (Addiction Severity Index)
200-item multidimensional structured
interview for assessing alcohol and drug
dependence. Assesses frequency of use without
addressing quantity of use. Useful instrument
to assess alcohol abuse Vs dependence in
women also.

 The ASI is a semi-structured interview
designed to address seven potential problem
areas in substance-abusing patients: medical
status, employment and support, drug use,
alcohol use, legal status, family/social status,
and psychiatric status.

 In 1 hour, a skilled interviewer can gather
information on recent (past 30 days) and
lifetime problems in all of the problem areas.
The ASI provides an overview of problems
related to substance, rather than focusing on
any single area.

9.CDP (Comprehensive Drinker Profile)
88 item structured instrument useful for the
assessment and treatment of alcohol problems.

10.Clinical Institute Withdrawal Assessment of
Alcohol Scale, Revised (CIWA-Ar)
The most objective and best-validated tool to
assess the severity of alcohol withdrawal is the
Clinical Institute Withdrawal Assessment for
Alcohol, Revised (CIWA-Ar). This survey
consists of 10 items and can be administered
rapidly at the bedside in about 5 minutes.

 The 10 items include nausea and vomiting,
anxiety, tremor, sweating, auditory
disturbances, visual disturbances, tactile
disturbances, headache, agitation, and clouding
of sensorium. Zero to 7 points are assigned to
each item, except for the last item, which is
assigned 0-4 points, with a total possible score
of 67.

ASSESSMENT OF NICOTINE USE
1.RTQ (Revised Fagerström Tolerance
Questionnaire)
10 item questionnaire designed to measure the
severity of nicotine dependence.

2.FTND (Fagerström Test for Nicotine Dependence)
Consists of six items from the RTQ. It assesses
the severity of nicotine dependence, tolerance
and withdrawal.
The Fagerström Test for Nicotine Dependence
is a standard instrument for assessing the
intensity of physical addiction to nicotine. The
test was designed to provide an ordinal
measure of nicotine dependence related to
cigarette smoking.

 It contains six items that evaluate the quantity of
cigarette consumption, the compulsion to use, and
dependence.
 In scoring the Fagerstrom Test for Nicotine
Dependence, yes/no items are scored from 0 to 1
and multiple-choice items are scored from 0 to 3.
The items are summed to yield a total score of 0-
10. The higher the total Fagerström score, the more
intense is the patient's physical dependence on
nicotine.

3. OTI (Opiate Treatment Index)
Structured instrument which provides
comprehensive measure of drug misuse. It
measures outcome in six domains.

ASSESSMENT OF OTHER DRUG USE
1.DAST (Drug Abuse Screening Test)
The Drug Abuse Screening Test (DAST)
was developed in 1982 and is still an
excellent screening tool. It is a 28-item self-
report scale that consists of items that
parallel those of the Michigan Alcoholism
Screening Test (MAST).

 The DAST has “exhibited valid psychometric
properties” and has been found to be “a
sensitive screening instrument for the abuse of
drugs other than alcohol.

2.OTI (Opiate Treatment Index)
Structured instrument which provides
comprehensive measure of drug misuse. It
measures outcome in six domains

 The Opiate Treatment Index (OTI) is a
structured interview designed to provide a
measure of the effectiveness of drug
treatments. The OTI measures 6 treatment
outcomes; drug use, HIV risk-taking behaviour,
social functioning, criminality, health status
and psychological functioning. The OTI in its
complete from takes 20-30 minutes to
complete.

3.SODQ (Severity of Opiate Dependence Scale)
5 section questionnaire which assesses opiate
dependence. It is useful to assess pattern and
quantity of drug use and various other aspects
of dependence.

4.BDEPQ (Benzodiazepine Dependence
Questionnaire)
The Benzodiazepine Dependence
Questionnaire (BDEPQ) is a item self report
questionnaire designed to measure dependence
on benzodiazepine tranquillisers sedatives and
hypnotics Items cover all aspects of the
dependence syndrome with the exception of
withdrawal symptoms Each item is rated on a
four point likert scale referring to experiences
in the last month .

 30 item questionnaire for measuring
dependence on benzodiazepines, sedatives and
hypnotics

5.LDQ (Leeds Dependence Questionnaire)
The LDQ measures substance dependence.
The instrument is capable of measuring change
in dependence and can therefore be used to
follow treatment progress and evaluate
treatment outcomes. The LDQ measures
dependence in abstinent patients. The LDQ has
been validated for use with alcohol and heroin
users and smokers.

 10-item, multiple choice self completion
questionnaire which is used most sensitive to
detect psychological dependence.

6.SDS (Severity of Dependence Scale)
The Severity of Dependence Scale (SDS) is a
5-item questionnaire that provides a score
indicating the severity of dependence on
opioids. Each of the five items is scored on a 4-
point scale (0-3). The total score is obtained
through the addition of the 5-item ratings. The
higher the score the higher the level of
dependence. The SDS takes less than a minute
to complete.

7.SDSS (Substance Dependence Severity Scale)
The SDSS is a semi-structured, clinician-
administered interview that assesses DSM-IV
dependence and abuse and ICD-10 harmful use
for alcohol and other drugs for the previous 30
days. It assesses frequency and severity of
symptoms.
Number of items: 7–10 screening questions for
alcohol and each drug category; 13 symptom
items .

 Reference
 Ambekar A.Basu D. Synopsis of the Clinical
Practice Guidelines on Management of Alcohol
Use Disorders Indian Psychiatric Society 2015
; 14

Screening instruments for Substance use disorders

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