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Center for Substance Abuse Treatment. Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1994. (Treatment Improvement Protocol (TIP) Series, No. 11.)

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Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases.

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Chapter 2 - Development of the Simple Screening Instrument For AOD Abuse

Routine screening for alcohol and other drug (AOD) abuse can be used to initiate the process of assessment by identifying a client's possible problems and determining whether he or she needs a comprehensive assessment. Ideally, a screening instrument for AOD abuse should have a high degree of sensitivity: it should be broad in its detection of individuals who have a potential AOD abuse problem, regardless of the specific drug or drugs being abused.

The AOD abuse screening instrument presented in this chapter was designed to encompass a broad spectrum of signs and symptoms for substance use disorders. These conditions are characterized by AOD use that leads to negative physical, social, and/or emotional consequences and loss of control over one's pattern and amount of consumption of the substance(s) of abuse.

The view of AOD abuse problems and disorders presented in this chapter and reflected in the screening instrument is consistent with that adopted by the World Health Organization and the American Psychiatric Association. Briefly stated, this view holds that AOD abuse disorders are biopsychosocial disorders, causing impairment and dysfunction in physical, emotional, and social domains. Certain cognitive and behavioral signs and symptoms are also associated with AOD abuse (see the observation checklist at the end of the screening instrument for AOD abuse). Although many of these latter signs and symptoms can be the result of various medical, psychiatric, and social problems, individuals with an AOD abuse disorder generally exhibit several of them.

The screening instrument for AOD abuse was developed by first identifying five primary content domains, which are described in the sections that follow. The screening questions then devised were assigned to one or more of these categories. These screening questions were adapted from existing tools found in the published literature. Because most of these existing tools were designed to screen for alcohol abuse, many items needed to be revised to address other drugs. The sources for the screening items included in the instrument are shown in Exhibit 2-1 .

Exhibit 2-1: Sources for Items Included in the AOD Screening Instrument.

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Exhibit 2-1: Sources for Items Included in the AOD Screening Instrument.

Domains Measured by the Instrument

AOD Consumption

A person's consumption pattern - the frequency, length, and amount of use - of AODs is an important marker for evaluating whether he or she has an AOD abuse problem. Questions 1, 10, and 11 in the AOD abuse screening instrument were formulated in order to help delineate an individual's consumption pattern.

Patterns of AOD consumption can vary widely among individuals or even for the same individual. Although substance use disorders often consist of frequent, long-term use of AOD, addiction problems may also be characterized by periodic binges over shorter periods.

Preoccupation and Loss of Control

The symptoms of preoccupation and loss of control are common in persons with substance use disorders. Preoccupation refers to an individual spending inordinate amounts of time concerned with matters pertaining to AOD use. Loss of control is a symptom usually typified by loss of control over one's use of AODs or over one's behavior while using AODs. These symptoms are measured by screening test questions 2, 3, 9, 11, and 12.

The symptom of preoccupation is marked by an individual's tendency to spend a considerable amount of time thinking about, consuming, and recovering from the effects of the substance(s) of abuse. In some cases, the individual's behavior may be noticeably altered by his or her preoccupation with these matters. Such an individual may, for example, lose interest in personal relationships or may become less productive at work as a result of constant preoccupation with obtaining more of the substance of abuse.

Loss of control over AOD use is typified by the consumption of more of the substance(s) of abuse than originally intended. Many persons with an AOD abuse problem feel that they have no direct, conscious control over how much and how often they use AOD. Such an individual may, for example, initially intend to have only one drink but then be unable to keep from drinking more. He or she may find it difficult or impossible to stop drinking once he or she has started. In other instances, a person who originally plans to use a drug for a short period of time may find that he or she is increasingly using it over longer periods than originally intended.

Loss of behavioral control, on the other hand, is typified by loss of inhibitions and by behaviors that are often destructive to oneself or others. In many cases, these behaviors do not occur when the individual is not using AODs. A person with an AOD problem may begin taking unnecessary risks and may act in an impulsive, dangerous manner. Individuals who are intoxicated from AOD abuse may, for example, have sex with someone in whom they ordinarily would not have a sexual interest, or they may start an argument or fight.

Adverse Consequences

Addiction invariably involves adverse consequences in numerous areas of an individual's life, including physical, psychological, and social domains. In the screening instrument for AOD abuse, questions 5-9, 12, and 13 are designed to elicit adverse consequences of AOD abuse.

Examples of adverse physical consequences resulting from AOD abuse include experiencing blackouts, injury and trauma, or withdrawal symptoms or contracting an infectious disease associated with high-risk sexual behaviors. One of the most serious health threats to AOD abusers, particularly those who inject drugs intravenously, is infection with human immunodeficiency virus (HIV), the causative agent of acquired immunodeficiency syndrome (AIDS).

Adverse psychological consequences arising from AOD abuse include depression, anxiety, mood changes, delusions, paranoia, and psychosis. Negative social consequences include involvement in arguments and fights; loss of employment, intimate relationships, and friends; and legal problems such as civil lawsuits or arrests for abuse, possession, or selling of illicit drugs.

As an individual's use continues over time and addiction takes hold, adverse consequences tend to worsen. Thus, people in the very early stages of addiction may have fewer adverse consequences than those in the later stages. Individuals in the early stages of addiction may therefore not make the connection between their AOD abuse and the onset of negative consequences. For this reason, some of the items directed at identifying AOD-related adverse consequences in the screening instrument attempt to obtain this information without making an overt association with AOD abuse.

Problem Recognition

Making a mental link between one's use of AOD and the problems that result from it - such as difficulties in personal relationships or at work - is an important step in recognizing one's AOD abuse problem. Questions 2-4 and 13-16 in the AOD abuse screening instrument are problem recognition items. Some of these items ask about past contacts with intervention and treatment services, because both research and clinical experience indicate that a history of such contacts can be a valid indicator of AOD abuse problems.

Some individuals who have experienced negative consequences resulting from their AOD abuse will report these problems during a screening assessment. Clients who show insight about the relationship between these negative consequences and their use of AODs, should be encouraged to seek help.

Many, if not most, people who abuse AODs, however, do not consciously recognize that they have a problem. Other reasons why a person may not disclose an AOD abuse problem include denial, lack of insight, and mistrust of the interviewer. These individuals cannot be expected to respond affirmatively to "transparent" problem recognition items - those in the form of direct questions, such as "Do you have an AOD problem?" - during a screening interview. For these individuals, questions must be worded indirectly in order to ascertain whether negative experiences have ensued from the use of AODs.

Tolerance and Withdrawal

AOD abuse, particularly prolonged abuse, can cause a variety of physiological problems that are related to the development of tolerance and withdrawal. Questions 5 and 10 are aimed at determining whether an individual has experienced any of the signs of tolerance and withdrawal.

Tolerance is defined as the need to use increasing amounts of a substance in order to create the same effect. If tolerance has developed and the individual stops using the substance of abuse, it is common for withdrawal effects to emerge.

Withdrawal from stimulants and related drugs often includes symptoms of depression, agitation, and lethargy; withdrawal from depressants (including alcohol) often includes symptoms of anxiety, agitation, insomnia, and panic attacks; and withdrawal from opiates produces agitation, anxiety, and physical symptoms such as abdominal pain, increased heart rate, and sweating.

Administration of the AOD Screening Instrument

Two versions of the AOD screening instrument are presented in this chapter. They have been designed to be administered in the form of either an interview (Exhibit 2-2 ) or a self-administered test (Exhibit 2-3 ) to individuals who may be at risk of having an AOD abuse problem.

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Exhibit 2-2: Simple Screening Instrument for AOD Abuse - Interview Form. Note: Boldfaced questions constitute a short version of the screening instrument that can be administered in situations that are not conducive to administering the entire (more...)

Exhibit 2-3: Simple Screening Instrument for AOD Abuse - Self-Administered Form.

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Exhibit 2-3: Simple Screening Instrument for AOD Abuse - Self-Administered Form.

Use of the screening instrument should be accompanied by a careful explanation of the subject's rights to confidentiality, as well as any limits on confidentiality (see Chapter 5). The interviewer should also be clear about the instrument's purpose and should make it understood that the information elicited from the instrument will be used to benefit, not to punish, the individual being screened.

Ideally, the screening test should be administered in its entirety. Situations may arise, however, in which there is inadequate time to administer the entire test. Street outreach community workers, for example, may have very limited time with an individual.

In such situations, a subset of the screening instrument can be administered. The four boldfaced questions - 1, 2, 3, and 16 - constitute the short form of the screening instrument. These items were selected because they represent the prominent signs and symptoms covered by the full screening instrument. Although this abbreviated version of the instrument will not identify the variety of dimensions tapped by the full instrument and is more prone to error, it may serve as a starting point for the screening process.

Notes on the Screening Questions

The screening instrument begins with a question about the individual's consumption of AODs (question 1). This question is intended to help the interviewer decide whether to continue with the interview - if the response to this first question is no, continued questioning may be unnecessary.

Questions 2-4 are problem recognition items intended to elicit an individual's assessment of whether too much AODs are being used, whether attempts have been made to stop or control AOD use, and whether previous treatment has been sought. Answers to these questions may help the service provider understand how the individual thinks and feels about his or her use of AODs. People who later report negative consequences as the result of their AOD use but who nevertheless answer "no" to these problem recognition questions may have poor insight about their AOD abuse or may be denying the severity of their AOD problem.

Questions 5-12 were designed to determine whether an individual has experienced any adverse consequences of AOD abuse. These include medical, psychological, social, and legal problems that often are caused by AOD abuse and addiction. Some questions are intended to elicit symptoms of aggression (question 9), physical tolerance (question 10) preoccupation (question 11), and loss of control (question 12). Question 13 is designed to tap feelings of guilt, which may indicate that the individual has some awareness or recognition of an AOD problem; questions 14 and 16 are intended to measure the respondent's awareness of a past or present problem; and question 15 elicits the individual's family history of AOD problems.

Parenthetical words or phrases that accompany some of the screening questions are intended to provide the interviewer with specific examples of what is being looked for or to help the respondent understand the question. For instance, question 1 asks whether an individual has used AOD, and the wording in parentheses prompts the administrator to ask about specific substances of abuse.

Scoring and Interpretation

A preliminary scoring mechanism for the screening instrument is provided in Exhibit 2-4 . Until an empirical evaluation of this scoring protocol is complete, however, it should be considered only as a guideline to interpreting responses to the instrument.

Exhibit 2-4: Scoring for the AOD Abuse Screening Instrument.

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Exhibit 2-4: Scoring for the AOD Abuse Screening Instrument.

Questions 1 and 15 are not scored, because affirmative responses to these questions may provide important background information about the respondent but are too general for use in scoring. The observational items are also not intended to be scored, but the presence of most of these signs and symptoms may indicate an AOD problem.

It is expected that people with an AOD problem will probably score 4 or more on the screening instrument. A score of less than 4, however, does not necessarily indicate the absence of an AOD problem. A low score may reflect a high degree of denial or lack of truthfulness in the subject's responses. The scoring rules have not yet been validated, and thus the AOD screening instrument needs to be used in conjunction with other established screening tools when making referrals.

Referral Issues

The AOD screening instrument, as a first step in the process of assessment for AOD abuse problems, can help service providers determine whether an individual should be referred for a more thorough assessment. When an individual with a potential AOD problem is identified through the instrument, the interviewer has the further responsibility of linking the individual to resources for further assessment and treatment.

Agencies and providers using the AOD screening instrument should be prepared to make an appropriate referral when the screening identifies a person with a possible AOD problem. A phone number written on a piece of paper is not likely to be effective in linking the individual to the appropriate resource for assessment and treatment. Rather, a thorough familiarity with local community resources is needed on the part of the service provider. The referring provider should take a proactive role in learning about the availability of appointments or treatment slots, costs, transportation needs, and the names of contact people at the agencies to which referrals are made. (See Chapter 5 for a discussion of the legal issues surrounding the referral process.)

Because many individuals identified as having possible AOD problems receive services from more than one agency, it is essential that one agency assume primary responsibility for the client. The ideal model is a case management system. Through personal contacts, case managers can help patients progress through various programs and systems, cut red tape, and remove barriers to access to services.

Providing effective services for AOD abuse requires close cooperation among agencies. Community linkages can help increase the quality of treatment for patients, whereas interagency competition decreases the quality of comprehensive care.

AOD abuse problems should be seen within the larger context of other problems, both current and past, confronted by the individual. Current problems such as instability in housing and employment, homelessness, and hunger often represent immediate needs that are more pressing for the individual than treatment for his or her AOD abuse. Past crises, such as incest, rape, and sexual abuse, can also affect how an individual responds to the screening questions.

Some of the items in the screening instrument may trigger emotional distress or a crisis. Reactions may sometimes include anxiety or depression, which may be accompanied by suicidal thoughts and behaviors. Agencies should therefore develop specific protocols to manage such crises. These protocols should include inhouse management and appropriate referrals and followup.

Glossary for AOD Abuse Screening

Agitation: A restless inability to keep still. Agitation is most often psychomotor agitation, that is, having emotional and physical components. Agitation can be caused by anxiety, overstimulation, or withdrawal from depressants and stimulants.

Blackouts: A type of memory impairment that occurs when a person is conscious but cannot remember the blackout period. In general, blackouts consist of periods of amnesia or memory loss, typically caused by chronic, high-dose AOD abuse. Blackouts are most often caused by sedative-hypnotics, such as alcohol and the benzodiazepines.

CAGE questionnaire: A brief alcoholism screening tool asking subjects about attempts to Cut down on drinking, Annoyance over others' criticism of the subject's drinking, Guilt related to drinking, and use of an alcoholic drink as an Eye opener.

Coke bugs: Tactile hallucinations (also called formications) that feel like bugs crawling on or under the skin. Chronic and high-dose stimulant abuse can cause various types of hallucinations.

Constricted pupils (pinpoint pupils): Pupils that are temporarily narrowed or closed. This is usually a sign of opiate abuse.

Convulsions: A seizure is a sudden episode of uncontrolled electrical activity in the brain. If the abnormal electrical activity spreads throughout the brain, the result may be a loss of consciousness and a grand mal seizure. One symptom of a seizure is convulsions or twitching and jerking of the limbs. Seizures may occur as the result of head injury, infection, cerebrovascular accidents, withdrawal from sedative-hypnotic drugs, or high doses of stimulants.

Crack: Cocaine (cocaine hydrochloride) that has been chemically modified so that it will become a gas vapor when heated at relatively low temperatures; also called "rock" cocaine.

Dilated pupils: Pupils that have become temporarily enlarged.

Downers: Slang term for drugs that exert a depressant effect on the central nervous system. In general, downers are sedative-hypnotic drugs, such as benzodiazepines and barbiturates.

DTs: Delirium tremens; a state of confusion accompanied by trembling and vivid hallucinations. Symptoms may include restlessness, agitation, trembling, sleeplessness, rapid heartbeat, and possibly convulsions. Delirium tremens often occurs in chronic alcoholics after withdrawal or abstinence from alcohol.

Ecstasy: Slang term for methylenedioxymethampheta-mine (MDMA), a member of the amphetamine family (for example, speed). At lower doses, MDMA causes distortions of emotional perceptions. At higher doses, it causes potent stimulation typical of the amphetamines.

Hallucinogens: A broad group of drugs that cause distortions of sensory perception. The prototype hallucinogen is lysergic acid diethylamide (LSD). LSD can cause potent sensory perceptions, such as visual, auditory, and tactile hallucinations. Related hallucinogens include peyote and mescaline.

Hepatitis: An inflammation of the liver, with accompanying liver cell damage and risk of death. Hepatitis may be of limited duration or a chronic condition. It may be caused by viral infection, as well as chronic exposure to poisons, chemicals, or drugs of abuse, such as alcohol.

Ice: Slang term for smokeable methamphetamine. Much as cocaine can be modified into a smokeable state (crack cocaine), methamphetamine can be prepared so that it will produce a gas vapor when heated at relatively low temperatures. When smoked, ice methamphetamine produces an extremely potent and long-lasting euphoria, an extended period of high energy and possible agitation, followed by an extended period of deep depression.

Legal problems: AOD abusers are at a higher risk for engaging in behaviors that are high risk and illegal. These behaviors may result in arrest and other problems with the criminal justice system. Examples of legal problems include driving while intoxicated, writing bad checks to obtain money for drugs, failure to pay bills and credit card debts, being arrested for possession or sale of drugs, evictions, and arrest for drug-related violence.

Marijuana: The dried leaves and flowering tops of the Indian hemp plan cannabis sativa; also called "pot" and "weed." It can be smoked or prepared in a tea or food. Marijuana has two significant effects. In the nontolerant user, marijuana can produce distortions of sensory perception, sometimes including hallucinations. Marijuana also has depressant effects and is partially cross-tolerant with sedative-hypnotic drugs such as alcohol. Hashish (or hash) is a combination of the dried resins and compressed flowers from the female plant.

Needle tracks: Bruising, collapsed veins, or a series of small holes on the surface of the skin caused by chronic injection of drugs into the veins (intravenous injection) or muscle (intramuscular injection) or under the skin (subcutaneous injection).

Nodding out: Slang term for the early stages of depressant-induced sleep. Opioids and sedative-hypnotics induce depression of the central nervous system, causing mental and behavioral activity to become sluggish. As the nervous system becomes profoundly depressed, symptoms may range from sleepiness to coma and death. Typically, "nodding out" refers to fading in and out of a sleepy state.

Opiates: A type of depressant drug that diminishes pain and central nervous system activity. Prescription opiates include morphine, meperidine (Demerol), methadone, codeine, and various opioid drugs for coughing and pain. Illicit opioids include heroin, also called "smack," "horse," and "boy."

Paranoia: A type of delusion, or a false idea, that is unchanged by reasoned argument or proof to the contrary. Clinical paranoia involves the delusion that people or events are in some way specially related to oneself. People who are paranoid may believe that others are talking about them, plotting devious plans about them, or planning to hurt them. Paranoia often occurs during episodes of high-dose chronic stimulant use and may occur during withdrawal from sedative-hypnotics such as alcohol.

Paraphernalia: A broad term that describes objects used during the chemical preparation or use of drugs. These include syringes, syringe needles, roach clips, and marijuana or crack pipes.

Self-help groups: Self-help groups differ from therapy groups in that self-help groups are not led by professional therapists. Some self-help groups, such as Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous, are called 12-step programs because they are based on the 12 steps or recommendations for living of Alcoholics Anonymous.

Skin abscesses: A collection of pus formed as a result of bacterial infection. Abscesses close to the skin usually cause inflammation, with redness, increased skin temperature, and tenderness. Abscesses may be caused by injecting drugs and impurities into the body.

Slurred speech: A sign of depressant intoxication. When people consume significant amounts of sedative-hypnotics and opioids, their speech may become garbled, mumbled, and slow.

Tremors: An involuntary and rhythmic movement in the muscles of parts of the body, most often the hands, feet, jaw, tongue, or head. Tremors may be caused by stimulants such as amphetamines and caffeine, as well as by withdrawal from depressants.

Unsteady gait: Unsteady, crooked, meandering, and uncoordinated walk, typical of alcohol-impaired individuals.

Uppers: Slang term used to describe drugs that have a stimulating effect on the central nervous system. Examples include cocaine, caffeine, and amphetamines.

Sources for the AOD Screening Questions

Addiction Severity Index: McLellan, A.T., Luborsky, L., Woody, G.E., and O'Brien, C.P. An improved diagnostic evaluation instrument for substance abuse patients: the Addiction Severity Index. Journal of Nervous and Mental Disease 186:26-33, 1980.

AUDIT: Babor, T.F., De La Fuente, J.R., and Saunders, J. AUDIT: Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva: World Health Organization, 1989.

CAGE: Mayfield, D., McLeod, G., and Hall, P. The CAGE questionnaire: validation of a new alcoholism screening instrument. American Journal of Psychiatry 131:1121-1123, 1974.

DAST: Skinner, H.A. Drug Abuse Screening Test. Addictive Behavior 7:363-371, 1982.

DSM-III-R: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, D.C.: American Psychiatric Association, 1987.

History of Trauma Scale: Skinner, H.A., Holt, S., Schuller, R., Roy, J., and Israel, Y. Identification of alcohol abuse using laboratory tests and a history of trauma. Annals of Internal Medicine 101:847-851, 1984.

MAST: Selzer, M.L. The Michigan Alcohol Screening test: the quest for a new diagnostic instrument. American Journal of Psychiatry 127:1653-1658, 1971.

POSIT: Rahdert, E.R. The Adolescent Assessment and Referral System Manual. DHHS pub. no. (ADM) 91-1735. Rockville, Md.: National Institute on Drug Abuse, 1991.

RHSS: Fleming, M.F., and Barry, K.L.: A three-sample test of a masked alcohol screening questionnaire. Alcohol 26:81-91, 1991.

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