Assessments for Substance Use Disorders

Introduction

Substance use disorders (also known as substance abuse) are a group of conditions where an individual experiences “the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.” (SAMHSA, 2015)

There are a variety of assessment tools used for determining the severity of the substance use disorder. These are reviewed below.

CAGE Alcohol Questionnaire

The CAGE Alcohol Questionnaire (O’Brien, 2008) is a four-item test to assess alcohol abuse. The letters “CAGE” are an acronym to help you remember the four questions:

1. Have you ever felt you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Each question is scored yes or no, with one point per yes. A score of 2 or higher represents clinically significant potential for alcohol abuse. (Malet, et. al., 2005) There is also a modified scale for Drug Use, below:

CAGE Questions Adapted to Include Drug Use (CAGE-AID)

The psychometric properties of the CAGE-AID were tested in Dyson et. al. (1998) where it was found to be an effective tool.

1. Have you ever felt you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Self-Administered Alcoholism Screening Test-Revised (SAAST-R)

The Self-Administered Alcoholism Screening Test (SAAST) was originally a 35-item self-administered test for alcohol abuse developed by Swenson & Morse in 1975 (see the Reference List for the citation – I haven’t been able to track down the original to read it.) It was updated by Vickers-Douglas, et. al. (2005) as the SAAST-R, and this is the version presented below.

The SAAST-R has shown good validity and reliability in subsequent studies (Patten, et. al., 2006)

SAAST-R Items

1. In your entire lifetime, have you ever had a drink of an alcoholic beverage?
2. Have you ever felt that you used more alcohol than the average person?
3. Have your close friends, relatives, or spouse ever worried or complained about your drinking?
4. Have you ever had to struggle to stop drinking after one or two drinks?
5. Have you always been able to stop drinking when you wanted to?
6. Have you ever found that over time you needed to drink more and more alcohol to get the same effect?
7. Have you ever gotten into physical fights when drinking?
8. Has your drinking ever created problems between you and your spouse, parents, or other people you care about?
9. Have you ever lost friendships because of your drinking?
10. Have you ever gotten into trouble at work or school
11. Have you ever lost a job because of your drinking?
12. Have you ever neglected your obligations, your family, your work, or school activities for two or more days in a row because of drinking?
13. Because of your drinking, have you ever given up or spent less time doing important recreational, social, or work activities?
14. Have you ever spent a lot of your time getting alcohol, drinking alcohol, or recovering from drinking?
15. Have you ever found that, over time, drinking the same number of drinks had less effect?
16. Have you ever used alcohol in the morning or at the beginning of the day?
17. Have you ever felt the need to cut down on you drinking?
18. Within several hours or days of not drinking or drinking less than usual, have you ever experienced: (count each of the following present as one “yes” for the total score)
    1. restlessness, anxiety, or pacing?
    2. shaking?
    3. trouble sleeping?
    4. nausea or vomiting?
    5. seizures?
    6. hearing voices, seeing things, or feeling things on your skin that were not really there?
19. Have you ever used alcohol to get rid of or reduce any of the above symptoms?
20. Have you ever used alcohol to prevent any of the above symptoms from occurring?
21. Have you ever had more to drink than you planned?
22. Have you ever been told by a doctor to stop drinking (not including when you were pregnant, nursing, or taking a medication that should not be used or taken with alcohol)?
23. Have you ever been a patient in a hospital or treatment facility because of problems related to your drinking?
24. Have you ever continued to drink despite knowing you had a physical problem (for example, blackouts, liver disease) or a mental health problem (for example, depression) caused or made worse by your drinking?
25. Have you ever been arrested, ever for few hours, because of driving while intoxicated?
26. Other than driving-related arrests, have you ever been arrested, even for a few hours, because of your behavior while drinking?
27. Have you repeatedly driven a car, truck, boat, or recreational vehicle or operated machinery when you had too much to drink?
28. Have you ever received treatment for alcoholism?
29. Have you ever attended a meeting of Alcoholics Anonymous (AA) because of your drinking?

The below items are used for the clinician’s benefit but are not calculated into the total score:

1. How recently have you used any alcohol?
   1. Never have 6 <1
   2. In the past month
   3. 2 to 3 months ago
   4. 4 to 6 months ago
   5. 7 to 9 months ago
   6. 10 to 12 months ago
   7. 13 months to 2 years ago
   8. 2.1 to 5 years ago
   9. More than 5 years ago
2. Which of the following best describes your entire life experience regarding use of alcohol?
   1. I have never used alcohol in my entire lifetime
   2. I currently use alcohol and I have never had a drinking problem
   3. I no longer use alcohol and I have never had a drinking problem
   4. I no longer use alcohol, but in the past I had a drinking problem
   5. I currently have a drinking problem
   6. Other

SAAST-R Scoring

In the original SAAST the cut-off score was greater-than or equal to 6 indicating the potential for alcoholism, with 10 indicating probable alcoholism (Davis & Morse, 1987), but in the revised SAAST-R the cut-off score is 4. (Patten, et. al., 2006) Given that the moderate to severe options explored in the original SAAST have not been validated yet, attempting to apply those ratings (e.g. equating a score of 10 on the SAAST-R with a score of 10 on the SAAST) should be done with caution.

Drug Abuse Screening Test (DAST)

The Drug Abuse Screening TEST (DAST) was developed as a 28-item self-report test for substance use or drug abuse by the Psychologist Harvey Skinner. It was based on the Michigan Alcohol Screening Test (MAST) but with the word alcohol changed to drugs. Subsequent review shortened the tool from 28 items to 20 and then to 10. It is now available in those two formats, the DAST-10 and the DAST-20.

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) provides a copy of the DAST-20 along with a review of its psychometric properties showing it is an effective tool for identifying struggling with addiction (2008).

The DAST-10 is available from the National Institute on Drug Abuse (n.d.). The DAST-20 and the DAST-10 have an extremely high reliability (r = 0.97) indicating they are virtually identical in their output scores. (Villalobos-Gallegos, 2015)

DAST Scoring

Each item in the DAST is scored yes or no, and the “yes” responses are summed to create a final score. On the DAST-20, a score of 6 or higher indicates an issue with drugs, while a score of 16 indicates severe addiction. (EMCDDA, 2008) on the DAST-20. The DAST-10 was found to have an optimal cut-off score of 4. (Evren, et. al., 2016)

Fagerstrom Test for Nicotine Dependence

The Fagerstrom Test for Nicotine Dependence is a 6-item tool for assessing nicotine dependence or severity of smoking addiction. It was developed in 1991 by Karl-Olov Fagerström. There are 3 yes/no items that are scored “0” (no) or “1” (yes), and 3 multiple choice items scored from 1-3. (NIDA, n.d.)

The items on the Fagerstrom Test are as follows (see the link for a printable version). The scores are in brackets:

• How soon after waking do you smoke your first cigarette?
  • Within 5 minutes (3)
  • 5-30 minutes (2)
  • 31-60 minutes (1)
• Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
  • Yes (1)
  • No (0)
• Which cigarette would you hate to give up?
  • The first in the morning (1)
  • Any other (0)
• How many cigarettes in a day do you smoke?
  • 10 or less (0)
  • 11 – 20 (1)
  • 21 – 30 (2)
  • 31 or more (3)
• Do you smoke more frequently in the morning?
  • Yes (1)
  • No (0)
• Do you smoke even if you are sick in bed most of the time?
  • Yes (1)
  • No (0)

The Fagerstrom Test has demonstrated fair reliability and validity but requires more comparative studies to test its validity. (Meneses-Gaya, 2009)

Fagerstrom Test Scoring

From the Brief Tobacco Intervention Training Program (BTITP) at Curtin University Australia comes the following scoring chart:

• Score of 1-2 = low dependence; monitor for withdrawal symptoms but no Nicotine Replacement Therapy (NRT) necessary
• Score of 3-4 = low to moderate dependence on nicotine; NRT can be offered
• Score of 5-7 = moderate to high dependence on nicotine; NRT can be offered alone or in combination (e.g. patches with lozenges and gum)
• Score of 8+ = high dependence on nicotine; NRT can be offered alone or in combination (e.g. patches with lozenges and gum)

The BTITP program provides a chart with recommendations for NRT:

More Information

More information can be obtained from the book “Sourcebook of Adult Assessment Strategies (Nato Science Series B:)”

References

Dyson, V. )., Appleby, L., Altman, E., Doot, M., Luchins, D., & Delehant, M. (1998). Efficiency and validity of commonly used substance abuse screening instruments in public psychiatric patients. Journal Of Addictive Diseases, 17(2), 57-76.

EMCDDA. (2008) EMCDDA | “Drug Abuse Screening Test (DAST-20)” Retrieved on July 31, 2016 from http://www.emcdda.europa.eu/html.cfm/index3618EN.html

Malet, L., Schwan, R., Boussiron, D., Aublet-Cuvelier, B., & Llorca, P. (2005). Original article: Validity of the CAGE questionnaire in hospital.European Psychiatry, 20484-489. doi:10.1016/j.eurpsy.2004.06.027

Meneses-Gaya, I.C., Zuardi, A.W., Loureiro, S.R., & Crippa, J.A. (2009). Psychometric properties of the Fagerström Test for Nicotine Dependence. Jornal Brasileiro de Pneumologia, 35(1), 73-82.https://dx.doi.org/10.1590/S1806-37132009000100011

NIDA. (n.d.) “Instrument: Fagerstrom Test For Nicotine Dependence (FTND) | NIDA CTN Common Data Elements”. National Institute on Drug Abuse. Retrieved on July 31, 2016 from http://cde.drugabuse.gov/instrument/d7c0b0f5-b865-e4de-e040-bb89ad43202b