An individual's relationship with alcohol and other drugs can be categorized as Abstinence, Non-Problem Use, Problem Use, Abuse, or Dependence. Of these five categories, Substance Abuse and Substance Dependence have been defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision*

*Institute of Medicine Broadening the Base of Treatment for Alcohol Problem National Academy Press, Washington D.C. (1990) page 30. Copyright 1990, 2000 The National Academy of Sciences, all rights reserved.)

Screening is used to assess whether or not an individual patient or client's relationship with alcohol or other drugs could be a problem. Like any other medical test, it allows health practitioners to quickly and easily identify whether or not there's a need for further workup. Substance abuse and addiction is the leading cause of death, disability and disease in the United States today, and costs $414 billion every year. Source: Substance AbusOne Health Problem (Robert Wood Johnson Foundation,
February 2001) . Alcohol and other drug screening should be part of every patient or client's intake and periodic check-up. Regular screening increases the practitioner's ability to detect and address problems early. Like cancer, diabetes, hypertension, and other chronic relapsing diseases, addiction is easier to manage earlier in the course of the disease. Users are all different, so it is important to know how to use many of these screening tools, depending on the individual patient or client's age, sex, background, and other psychosocial variables. Adolescent substance use has become a public health priority so it is particularly important to use screening tools developed for adolescents (like CRAFFT).

What follows is a list of screening and assessment tools. The majority of these evidence-based tools were drawn from Center for Substance Abuse Treatment's Treatment Improvement Protocol (TIP) Series 31 and 24. When selecting the tools you want to incorporate into your clinical practice, be sure to consider things like the time and equipment available for screening purposes, and the population of patients or clients to be screened. The general algorithm for practitioners-in-training is to first learn if the patient or client uses alcohol or other drugs and then to quantify how much. The NIAAA-developed Health Practitioner's Guide to Helping Patients with Alcohol Problems recommends this two-step screening for alcohol abuse or dependence.

Q U E S T I O N ST O A S K

Includes CAGE, DRAFTS, RAPS4-QF, TWEAK, T-ACE, NET,, CRAFFT AUDIT, and POSIT.

For Adults: CAGE, DRAFTS and RAPS4-QF

CAGE (Available in HTML format)
For use in: Adults. CAGE is the most commonly used and widely taught addiction screening tool. It was designed to distinguish those with alcoholism from those without, although it is sometimes used to flag other drug dependencies. In the field of alcohol and other drug screening tools, CAGE is the standard by which other tools are measured. (download a printable, wallet-sized screening card with CAGE and CRAFFT tools-pdf format)

DRAFTS (For Assessment of Alcohol Abuse or Dependence in Culturally Diverse Populations)
For use in: Adults

DRAFTS Questions:
(For Alcohol Abuse or Dependence Assessment in Culturally Diverse Populations)
D--Do you ever get the feeling that anyone DISAPPROVES of your drinking/drug use?
This is similar to the "annoyed" question in the CAGE questionnaire. However, in some cultures, women, in particular, would never act "annoyed" by their spouse's drinking, but rather might communicate something more subtle, like disapproval.
R--Do you drink alcohol or use drugs at any REGULAR times?
This question will provide information about the social context of use and issues surrounding the "Cutting Down" question in CAGE--especially when use is habitual, but there is no desire or perceived need to cut down.
A--Do you ever drink or use drugs when you are ALONE? Frequent use when alone--outside of a social setting--may raise suspicion of abuse or dependence.
F--Do any of your FRIENDS or FAMILY members drink alcohol or use drugs? Are there any problems? Information gathered using this question will allow the provider to determine peer and family influences, and the patient's criteria for problematic use.
T--Have you ever had any TROUBLE because of drinking/drug use? (home, work, legal)
Information about consequences of use can be collected without reference to the culturally variable concept of "Guilt."
S--Has alcohol/drug use ever made you feel SICK? (headaches, stomach problems, diarrhea, shakiness? During use? After use?) What makes you feel better? Medical consequences, symptoms of withdrawal, hangovers, etc. can be identified using this question. This allows investigation of issues related to physical addiction without reference to an "eye-opener"--an American middle class concept. (Source: Project ADEPT, Alcohol and Drug Education for Physician Training, Vol. V, "Race, Culture and ethnicity." Editors: Dube, C. & Lewis, D., July 1994, Unit 6, p. 14.)

RAPS4-QF
For use in: Adults

Based on the Alcohol Research Group's 2000 National Alcohol Survey, RAPS4-QF outperformed CAGE across all gender, ethnic, and service-utilization groups in detecting alcohol abuse among both males and females reporting emergency-room (ER) use.

To use the RAPS4-QF, add the following QF questions to the RAPS4 test:
Q: Have you had more than five drinks in one sitting?
F: On average, have you had a drink as or more often than once a month?

For Women of Reproductive Age: TWEAK, T-ACE, and NET

TWEAK (Available in .pdf format)
For use in: Adult Women
TWEAK is one of the few alcohol screening tests that has been developed and validated among women.

T-ACE (Available in HTML format)
For use in: Adults
T-ACE is a measurement tool of four questions that are significant identifiers of risky drinking during pregnancy.

NET (Available in HTML format)
For use in: Reproductive Age Women
The NET is a 3-item measure for detecting excessive alcohol consumption among women of reproductive age.

For Adolescents: CRAFFT, AUDIT, POSIT

CRAFFT Substance Abuse Screening Test (download adolescent screening card)
For use in: Adolescents
CRAFFT is a commonly accepted screening tool designed specifically for use with adolescents. The CRAFFT test screens for other drugs as well as for alcohol. (download a printable wallet-sized screening card with CAGE and CRAFFT tools)

AUDIT
For use in: Adults and Adolescents
Used for suspected heavy drinkers or alcoholics. It's a longer, 10-item tool administered via paper and pencil or by interview. Variable cutoffs allow the scorer to distinguish between harmful use, hazardous use, and dependence. See the WHO's AUDIT .pdf document for a more extended discussion.

POSIT, Problem Oriented Screening Instrument for Teenagers (POSIT) (Available in HTML )
For use in: Adolescents
POSIT is a self-administered 139-item "yes/no" screening questionnaire. It was developed for use with adolescents aged 12-19, and is designed to identify potential problem areas that require further in-depth assessment.

For an extensive list of screening and assessment tools, see the NIAAA Brief Screening Instruments. You can find a more in-depth discussion of screening specific to adolescent substance use disorders at the Center for Substance Abuse Treatment's Treatment Improvement Protocol (TIP) Series 31 Appendix B.

Treatment Assessment Instruments:
You can find a more extended discussion of screening specific for adolescent substance use disorders at the Center for Substance Abuse Treatment's Treatment Improvement Protocol (TIP) Series 31 Appendix B:

If a patient or client screens as likely to have problem use, abuse, or dependence, there are several subsequent steps that can be taken. One of these steps is the joint negotiation of a plan to modify, reduce, or abstain from use (see treatment for more information). If a patient or client needs more intensive treatment or would benefit from a clinical diagnosis, a more thorough assessment is indicated.

There are five categories of assessment tools:
•Assessment of Drinking Behavior
•Diagnostic Assessment
•Treatment Planning
•Treatment and Process Assessment
•Outcome Evaluation

•Assessments of Drinking Behavior are used to identify the level of severity for which a patient or client uses alcohol or other drugs. If substance abuse or dependence is suspected from a positive screening test, these lengthy assessments are an essential way to establish a baseline understanding of the client's unique usage patterns.

•Diagnostic Assessments are used to qualify which usage category (Abstinence, Non-Problem Use, Problem Use, Abuse, or Dependence) a patient or client fits into. This is important, because different diagnoses have different treatment interventions and prognoses. Frequently these assessments evaluate other potential issues, like psychosocial stressors or other problems associated with substance use, abuse and dependence

•Treatment Planning is used to individualize the treatment goals and outcome for a given patient or client. Every patient or client presents from a different milieu of psychosocial conditions, so setting an appropriate treatment course and establishing outcomes is important. Patients are placed into an appropriate level of care according to the American Society of Addiction Medicine's Patient Placement Criteria

•Treatment and Process Assessment is used after a treatment plan has been established to monitor a patient or client's individual progress.

•Outcome Evaluation is used after a patient or client completes treatment. More frequent use of outcome evaluations is essential to making evidence based improvements to, and comparative evaluations of, different treatment plans. Please see the National Institute on Alcohol Abuse and Alcoholism Treatment Assessment Instruments page for an extensive charted list of each of these instruments according to their categories. Assessment instruments specific for adolescents are reviewed at the Center for Substance Abuse Treatment's Treatment Improvement Protocol (TIP) Series 31 Appendix B.

The National Institute for Drug Abuse has developed a list of thirteen principles of effective drug addiction treatment. These principles should inform all health professionals-in-training as they learn intervention techniques and treatment plans.

Of these, the principle that no single treatment is appropriate for all individuals is the reason there are many intervention modalities listed on this site. Dr. David Smith has a good discussion about this point on his website. In the case of risky alcohol use, NIAAA's Health Practitioner's Guide for primary care practitioners, recommends a brief intervention that depends on the client's current level of use and CAGE score, although above-cutoff scores from other screening instruments are also valid in the context of this guide. NIAAA recommends that health professionals advise and assist at-risk patients or clients by stating their concern, introducing recommendation, and gauging readiness. If the patient or client is ready, negotiate an action plan to reduce use or abstain. NIAAA also recommends that practitioners arrange a follow up visit for their patient or client, to assess patient or client progress. If a health practitioner feels that the further assessment of their patient or client's use is necessary, they may want to use NIAAA's suggested diagnostic assessment based on the DSM-IVTR. (Click here for more NIAAA developed information for patients and clients.)

If a patient or client is going to need more help than can be provided by a health practitioner, then referral to another treatment center is indicated. (Click here for SAMHSA information on referral to alcohol treatment programs). It is important that patients or clients know that if necessary, health professionals can help them get into treatment. There are a variety of state chapters and professional organizations you can refer to for more information: The American Society of Addiction Medicine, The American Academy of Addiction Psychiatry and The Center for Substance Abuse Treatment. Please consult the Center for Substance Abuse Treatment's Treatment Improvement Protocol (TIP) Series 24: A Guide to Substance Abuse Services for Primary Care Clinicians for an extended discussion of these important resources.

Treatment centers vary widely in the treatment modalities they use. Many treatment centers are abstinence-based and built around a 12 step model. Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, and Crystal Meth Anonymous are all 12 step associations.

Some patients and clients that desire to modify, reduce, or eliminate their usage don't respond to 12-step programs, and need other interventions. There are a wide variety of alternatives to Alcoholics Anonymous' 12-step program. (Click here for a discussion of harm reduction approaches to alcohol use.) Among many other modalities, the article discusses a group-based alternative to AA known as Moderation Management. The basic NIAAA framework can be applied to most other drugs of abuse. In the case of frequently injected drugs like heroin, cocaine, and methamphetamine, health professionals should first assess usage levels, then screen for substance abuse or dependence, and potentially conduct a diagnostic or other assessment if indicated. (Click here for NIAAA's diagnostic assessment). Please also see the assessment page for a discussion of the variety of assessments available to health practitioners.

Health professional students working with injection drug users should know about harm reduction interventions. These usually take the form of sterile syringe exchanges. Health practitioners should encourage injection drug using patients or clients to take advantage of the clean needles, condoms, and information disseminated through these important public health service centers. Some of these centers, like Los Angeles' Clean Needles Now have websites with information to help people inject safely.
See the North American Syringe Exchange Network's website for a list of syringe exchange programs in the United States and Canada. Needle exchange programs have been shown to reduce the incidence of blood borne infections among injection drug users. They have not been shown to increase the incidence of injection drug use.

For more information about Harm Reduction in general, check out the
Harm Reduction Coalition. Patients or clients who are not motivated to modify, reduce, or abstain from substance use may benefit from an interviewing technique known as the Motivational Interview. To learn more about this cutting-edge technique, see the Motivational Interviewing Network.

There are several medications available to help patients or clients reduce or eliminate their substance use. These rarely work apart from other behavioral based-care, but their utility as useful adjuncts to care has been demonstrated. For information about these treatment modalities, see SAMHSA' s Center for Substance Abuse Treatment's Medications Page.

There is an extensive array of curricula available on the internet to help teach health professional students excellent intervention and treatment skills for dealing with patients or clients with problem substance use, abuse or dependence.

The first is Project MAINSTREAM (Multi-Agency Initiative on Substance Abuse Training and Education for America), a collaboration between the Health Resources and Services Administration, the Association for Medical Education and Research in Substance Abuse, and the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment. Project Mainstream offers a comprehensive syllabus, course materials, databases, and presentations for a wide variety of health professionals, including Dentists, Nurses, Occupational and Physical Therapists, Pharmacists, Physicians, and Social Workers (among others). The site is navigable by subject and by discipline.

The Center for Substance Abuse Prevention has developed an extensive Treatment Improvement Protocol Series. Please pay particular attention to TIP series 24: A Guide to Substance Abuse Services for Primary Care Clinicians and TIP series 31: Screening and Assessing Adolescents For Substance Use Disorders

The Center for Substance Abuse Prevention has a training library containing training curriculum for Dentists, Physicians, Physicians Assistants and other Allied Health Professionals. These are one or two-day courses designed to help health professional teams increase their substance abuse prevention activities, including prevention of alcohol, tobacco, and other drug use.

CSAP Training Curricula

Dental Team Curriculum: ATOD Problem Prevention
Physician Curriculum: ATOD Problem Prevention
Physician Assistant Curriculum: ATOD Problem Prevention
Prevention Works: Mental Health Specialists Course on Prevention of ATOD Problems
Prevention Works: Social Worker Training Course on Prevention of ATOD Problems
Prevention Works: Nurse Training Course on Prevention of ATOD Problems
The Alcohol Medical Scholars Program has a collection of ready-to-use curricula designed to teach the identification and care of people with alcohol use disorders and other substance-related problems.

Medication-assisted treatment has become a vital modality in the world of treatment for substance abuse or dependence. See SAMHSA's Center for Substance Abuse Treatment's Medications Page for an overview of currently available medication-assisted treatment, including methadone maintenance therapy.

The National Institute on Drug Abuse has several publications for students, teachers, parents, and allied health professionals. See their catalog.

Athealth.com is a leading provider of mental health information and services for mental health practitioners and those they serve.