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.