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Screening is a preliminary evaluation that attempts to determine
whether key features of drug abuse are present in an individual. Screening
indicates whether the problem of drug abuse is likely to be present.
Assessment is a thorough evaluation designed to definitively establish
the presence or absence of a diagnosable drug abuse problem. The results
of the assessment also suggest what is likely to be the most appropriate
type of treatment when drug problems are evident.
Why are screening and assessments necessary?
The aim of screening is to identify as many potential or actual abusers
as early in their use or abuse history as possible so appropriate
intervention services can be provided. Thus, the process is twofold.
Individuals are screened to identify the potential presence of an
alcohol- or drug-related problem, while the assessment stage takes
the process a step further and confirms the existence of a problem,
identifies the nature of the problem(s), and suggests appropriate
avenues of treatment.
Who is qualified to screen and assess?
Clinicians, counselors, family physicians, coworkers, families, friends,
and even addicts themselves can do screenings. This initial step,
as mentioned above, identifies a person as a possible drug abuser.
It is important to recognize the importance of this step. For drug
abusers, screening is often the first step toward recovery. To that
end, professionals, as opposed to untrained individuals, may be the
best individuals to conduct such evaluations.
When the screening indicates a likely problem, a clinician, counselor,
or family physician will want to use a diagnostic interview to determine
whether and to what extent the individual’s drug use satisfies
established criteria for abuse.
How are such assessments performed?
There are two types of interviews that can be utilized during the
assessment phase – structured and semi-structured. Structured
interviews provide a prearranged sequence of questions that permit
untrained individuals to assess reliably. Semi-structured interviews
are designed to guide trained mental health professionals in conducting
detailed examinations of patients. Although structured interviews
yield reliable diagnoses, they do not provide as much information
for treatment planning as do semi-structured interviews, which rely
more heavily on the interviewer’s expertise and professional
training and experience.
Are there any techniques to get the individual
to embrace the concept of treatment?
Aside from court mandated treatment, with which the addict is given
little choice, a number of approaches can work, depending on the individual.
Interventions, for example, in which loved ones confront the addict
with their personal concerns and fears is often a powerful way to
shock addicts into treatment. The decision to seek or not to seek,
however, treatment is ultimately up to the individual addict.
Can I tell if someone is abusing alcohol
or other drugs?
It is very difficult to identify alcoholics or drug addicts, sober
or intoxicated, just by watching and talking to them. When they are
sober, drug abusers tend to behave very similar to non-abusers, especially
if they are young or at the beginning of their abuse. Moreover, just
because someone has had too much to drink or has ingested an intoxicating
drug is no guarantee that he or she is an alcoholic or drug addict.
What tools are available to screen for alcohol
or drug abuse?
The two most widely used self-report screening instruments for alcoholism
are the 4-item CAGE and the 25-item Michigan Alcoholism Screening
Test (MAST). Both the CAGE and the MAST solicit Yes-No responses to
questions about common consequences of alcohol misuse. The CAGE asks
the following: “Have you ever: 1) attempted to Cut
back on alcohol? 2) been Annoyed by comments made
about your drinking? 3) felt Guilty about drinking?
4) had an Eye-opener first thing in the morning to
steady your nerves? These instruments are widely used because they
combine brevity with sensitivity, although they are of limited usefulness
with persons who do not want their abusive drinking known.
The Alcohol Use Inventory (AUI) is another widely used screening
instrument for adults suspected of problem drinking. The AUI is a
self-report instrument designed to assess 24 different behaviors,
feelings, and attitudes associated with the use and abuse of alcohol.
Because the instrument focuses on problematic drinking, it is not
suitable for persons who are unable or unwilling to acknowledge existing
drinking problems.
The Substance Abuse Subtle Screening Inventory (SASSI) is used to
identify alcohol and drug abusers and differentiate them from social
drinkers and general psychiatric clients. The SASSI is a single-page
questionnaire. On one side are 52 True-False questions that seem to
be unrelated to chemical abuse. On the other side are the Risk Prediction
Scales that allow clients to self-report on 12 alcohol-related and
14 drug-related items. The SASSI’s ease of administration and
scoring, its clear suggestions for interpretation, and the informative
and carefully written manual make it very attractive for practitioners,
such as individuals with Employee Assistance Programs (EAPs).
What tools are available to assess for alcohol
or drug abuse?
The Addiction Severity Index (ASI) is the most widely used measure
of problem severity among addicted clients entering treatment. This
interview was developed to serve as a standardized and reliable instrument
for evaluating drug-abusing clients. The interview is used frequently
in both traditional research settings and as an outcome measure in
clinical settings. It has been expanded to specialized populations,
such as cocaine-abusing mothers, opiate-dependent people, federal
prisoners, and homeless people.
The ASI covers the client’s medical status, employment and
support status, drug use, alcohol use, legal status, family and social
relationships, and psychiatric status. Clients are asked to respond
to specific questions about the problems they have experienced, both
within the past 30 days and over their lifetimes. Thus, both urgent
and chronic concerns are identified by ASI. Client answers to the
ASI inquiries are summarized into composite scores and are used to
measure changes over time in response to treatment.
In addition to these client-based ratings, the interviewer makes
an independent rating of the severity of each problem area, on the
basis of the interviewer’s experience with the client during
the interview. This rating starts at 0 (no problem exists) and ends
at 9 (an extreme problem exists and treatment is absolutely necessary).
The Diagnostic Interview Schedule-IV (DIS-IV), an interview based
on the 4th edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV), is the most widely used structured diagnostic
interview. The DIS offers diagnoses on a variety of disorders, including
schizophrenia, pathological gambling, and alcohol and drug dependence.
The DIS remains the leading interview for the diagnosis of disorders
by individuals untrained in the discipline of psychiatry.
What factors should be considered when deciding
on the most appropriate instrument?
- Ease of use
- Expertise and time required of staff to administer and score
test
- Possibility of bias (cultural or administrative)
- Validity (does it measure what it is intended to measure?) and
reliability (do re-tests yield identical results?)
- Credibility of test among academic and treatment professionals
- Adaptation of test to management information system (MIS) input
and retrieval
- Availability in languages other than English
- Motivation level and verbal and reading skills required of persons
to be assessed
- Average cost per test
How appropriate are these tools for workplace
settings?
There are tools appropriate for the workplace. Given the non-clinical
setting, the desire to get accurate results quickly, and the likelihood
that employees will not be willing to admit to their alcohol and/or
drug use habits, the most appropriate tool is the Substance Abuse
Subtle Screening Inventory (SASSI). As mentioned above, its length
and ease of administration is ideal for employers or other individuals
charged with managing EAPs.
What are the capabilities of drug testing?
Drug testing, such as through urinalysis, provides an objective or
impartial measure of drug use. This objective measure stands in contrast
to self-report measures of drug use, in which individuals are asked
to describe subjectively their alcohol- or drug-using behaviors. Research
has consistently documented that objective measures of drug use are
more reliable indicators of actual drug use than self-report measures.
Simply put, individuals are naturally inclined to hide embarrassing
behaviors when given the chance to do so. Drug tests greatly reduce
the likelihood of hiding recent drug-using behaviors.
Drug tests, like urinalysis, detect the presence of most drugs within
72 hours of use. After this window has passed, most drugs become undetectable.
The exception is marijuana, which can be detected in urine for up
to 30 days. Most drug tests cannot, however, identify historical use
or drug dependence. Drug tests can only stipulate whether an individual
has used a particular drug recently.
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