Substance Use Disorder Evaluations
Learn About the Many SUD Assessment Tools
Comprehensive Diagnostic Evaluations at J. Flowers Health Institute
The information presented on this page is an overview of the average evaluation of this nature and is offered here as a resource. At J. Flowers Health Institute, our evaluations are customized and tailored to the individual’s needs. We specialize in providing truly comprehensive health and wellness evaluations and a workable plan for future health to those who want to improve their quality of life.
If you would like to learn more about J. Flowers Health Institute, please do not hesitate to reach out.
We welcome any questions you have: 713.783.6655
Table of Contents
- What is a Substance Use Disorder?
- CAGE Substance Use Disorder Evaluation
- ASSIST Evaluation
- AUDIT Substance Use Disorder Evaluation
- AUDIT-C Evaluation
- CRAFFT Substance Use Disorder Evaluation
- MAST Evaluation
- DAST Substance Use Disorder Evaluation
- Fagerstrom Test
- TWEAK Evaluation
- NIDA Drug Screening Tool
- Other Ways to Screen
- Motivating a Patient to Recover
- Treating Substance Use Disorder
What is a Substance Use Disorder?
What is a substance use disorder evaluation? Why is a SUD evaluation important? Substance use disorders are diseases that affect a person’s brain and behavior. Prolonged substance use can lead to dependence and cravings, meaning that the body becomes dependent on a specific substance to function. The way that addiction occurs is that substances activate the brain’s reward systems, which produce feelings of pleasure, relaxation, and euphoria. The rewards felt from taking abusing substances are so great that people will continue to use despite negative consequences. While some people are more susceptible to substance use disorders than others, almost everyone is at risk of developing a substance use disorder if they abuse substances. J. Flowers Health Institute uses its comprehensive diagnostic evaluations to find out if recovery from addiction needs to be part of the treatment plan.
What are the Symptoms of Substance Use Disorder?
The DSM-5 outlines 11 different criteria that are used to determine the presence of a substance use disorder.1 The number of criteria that apply to a patient will determine the severity of their disorder. The 11 criteria, as outlined by the DSM-5, are:1
Taking the substance in larger amounts or for longer than you're meant to.
Wanting to cut down or stop using the substance but not managing to.
Spending a lot of time getting, using, or recovering from use of the substance.
Cravings and urges to use the substance.
Not managing to do what you should at work, home, or school because of substance use.
Continuing to use, even when it causes problems in relationships.
Giving up important social, occupational, or recreational activities because of substance use.
Using substances again and again, even when it puts you in danger.
Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
Needing more of the substance to get the effect you want (tolerance).
Development of withdrawal symptoms, which can be relieved by taking more of the substance.
- Having 2 or 3 of the above symptoms indicates a mild substance use disorder.
- Displaying 4 or 5 symptoms indicates a moderate substance use disorder.
- Having 6 or more symptoms indicates a severe substance use disorder.1
What are the Risk Factors of Substance Use Disorder?
When conducting screening for substance use disorders, it is crucial to be aware of risk factors of substance use that might require closer examination. For example:
Family history of substance use disorder
Problems at school or work can indicate substance use disorder
It is important to consider the factors that may lead someone to use substances when conducting the screening.
Although the DSM-5 outlines the diagnostic criteria for substance use disorders, there are more specific screening tools used for specific disorders.
Substance Use Disorder Assessment Tools:
- Fagerstrom Test
- NIDA Drug Screening Tool
CAGE Substance Use Disorder Evaluation
CAGE is a substance use disorder evaluation that asks about lifetime alcohol or substance consumption. There are four questions to the CAGE questionnaire:2
Have you ever felt you ought to Cut down on your drinking or substance use?
Have people Annoyed you by criticizing your drinking or substance use?
Have you ever felt bad or Guilty about your drinking or substance use?
Have you ever had a drink or used substances first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover (or to get the day started)?
Patients will answer the questions either yes or no. For women, as low as one “yes” answer can signify a possible substance use disorder. For men, 1 or 2 “yes” answers may indicate the presence of a substance use disorder.2 Because there are so few questions as part of the CAGE questionnaire, it might not always be the best form of evaluation, particularly in more complex cases.
The ASSIST substance use disorder evaluation stands for the Alcohol, Smoking, and Substance Involvement Screening Test, which was developed for the World Health Organization by a group of international substance abuse researchers. It is designed for use in primary health care settings where a patient’s substance use might otherwise go undetected. ASSIST is a questionnaire with 8 items that takes about 5-10 minutes to administer. ASSIST is typically comprised of the following questions:
Which substances have you used in your lifetime?
What is the frequency of substance use in the past three months?
What is the frequency of experiencing cravings or urges to use in the last three months?
What is the frequency of health, social, legal, or financial problems experienced in relation to substance use in the past three months?
What is the frequency with which substance use has interfered with your responsibilities in the past three months?
Has anyone ever expressed concern about your substance use? If so, when?
Have you ever tried to cut down or stop the use of substances and failed? If so, when?
Have you ever injected any substances, and if so, when?
The answers to this questionnaire provide information about the level of risk associated with the patients’ substance use. Scoring involves adding the scores from Questions 1-7. Question 8 is not included in the evaluation of substance use but is an indicator of risk as injecting drugs is a high-risk activity.
What Substances Does ASSIST Screen For?
ASSIST is used to screen for the use of the following substances:
AUDIT Substance Use Disorder Evaluation
The AUDIT substance use disorder evaluation stands for the Alcohol Use Disorders Identification Test, which is a simple test that screens for alcohol abuse.3 Since its publication in 1989, AUDIT has become the world’s most widely used alcohol screening tool and is available in over 40 languages. AUDIT also provides a framework for intervention by identifying alcohol dependence and the consequences of alcohol abuse.3 AUDIT is typically administered by health care providers but can also be self-administered. The items of AUDIT look into three main things:3
Dependence on alcohol
1. How often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
3. How often do you have six or more drinks on one occasion?
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
6. How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session?
7. How often during the last year have you felt guilty after drinking?
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?
9. Have you or someone else been injured due to your drinking?
10. Have your friends, family, or doctor expressed concern about your drinking or suggested you cut down?
Each question has 3-5 potential answers that range in point value from 0-4. More than 8 total points in the questionnaire indicate harmful alcohol use.3
How often do you drink alcohol?
- Monthly or less
- 2-4 times a month
- 2-3 times a week
- 4 or more times a week
How many standard drinks containing alcohol do you have on a typical day?
How often do you have six or more drinks on one occasion?
- Less than monthly
- Daily/almost daily
Answers range in point values from 0-4. A total of 4 or more points identified potentially hazardous drinking in men, and a score of 3 or more identifies potentially hazardous drinking in women.4 In general, the higher the score, the more likely it is that drinking is affecting their life.
CRAFFT Substance Use Disorder Evaluation
The CRAFFT substance use disorder evaluation is a screening tool that identifies substance use, substance-related driving risk, and substance use disorder among youth ages 12-21 and is often used for early intervention.5 CRAFFT is the most widely used screening tool for adolescents and has proven to be useful for adolescents of various socioeconomic and ethnic backgrounds.5
There are two versions of CRAFFT, an interview with a healthcare provider or a self-administered questionnaire.5 The benefits of self-administered questionnaires are that patients are more likely to be honest when filling out a questionnaire rather than being asked face to face about their use.
A typical CRAFFT questionnaire looks like this:5
Answer yes or no to the following questions.
In the past 12 months, did you drink any alcohol? (do not count sips of alcohol taken during family/religious events)
In the past 12 months, did you smoke any marijuana or hashish?
In the past 12 months, did you use anything else to get high? (e.g., illegal substances, over the counter prescription drugs, inhalants, etc.)
Answer yes or no to the following questions.
Have you ever ridden in a Car driven by someone (including yourself) who was “high” or had been using alcohol or drug?
Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
Do you ever use alcohol or drugs while you are by yourself, or Alone?
Do you ever Forget things you did while using alcohol or drugs?
Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into Trouble while you were using alcohol or drugs?
CRAFFT Screening Tool for Adolescent Substance Abuse
Part A: If “yes” to any questions in Part A, ask all 6 CRAFFT questions. If “no,” ask CAR question, then stop.
Part B: Score 1 point for each “YES” answer.
The MAST substance use disorder evaluation stands for the Michigan Alcohol Screening Test, which was developed in 1971 and is one of the oldest alcohol screening tests available.6 The MAST test is a 22 item questionnaire that can be administered by a healthcare professional or can be self-administered. The MAST test typically looks like this:6
Answer yes or no to the following questions:
Question Directed at Your Drinking
1. Do you feel you are a normal drinker? ("normal" is defined as drinking as much or less than most other people)
2. Have you ever awakened the morning after drinking the night before and found that you could not remember a part of the evening?
3. Does any near relative or close friend ever worry or complain about your drinking?
4. Can you stop drinking without difficulty after one or two drinks?
5. Do you ever feel guilty about your drinking?
6. Have you ever attended a meeting of Alcoholics Anonymous (AA)?
7. Have you ever gotten into physical fights when drinking?
Questions About Family and Work
8. Has drinking ever created problems between you and a near relative or close friend?
9. Has any family member or close friend gone to anyone for help about your drinking?
10. Have you ever lost friends because of your drinking?
11. Have you ever gotten into trouble at work because of drinking?
12. Have you ever lost a job because of drinking?
13. Have you ever neglected your obligations, family, or work for two or more days in a row because you were drinking?
14. Do you drink before noon fairly often?
Questions About the Consequences of Your Drinking
15. Have you ever been told you have liver trouble, such as cirrhosis?
16. After heavy drinking, have you ever had delirium tremens (DTs), severe shaking, visual or auditory (hearing) hallucinations?
17. Have you ever gone to anyone for help with your drinking?
18. Have you ever been hospitalized because of drinking?
19. Has your drinking ever resulted in your being hospitalized in a psychiatric ward?
20. Have you ever gone to any doctor, social worker, clergyman, or mental health clinic for help with any emotional problem in which drinking was part of the problem?
21. Have you been arrested more than once for driving under the influence of alcohol?
22. Have you ever been arrested, or detained by an official for a few hours, because of other behavior while drinking?
Score one point if you answered “no” to questions 1 or 4. Score one point if you answered “yes” to the remaining questions. A score of six or more indicates dangerous drinking or alcohol dependence, and further evaluation is recommended.6
DAST Substance Use Disorder Evaluation
The DAST substance use disorder evaluation stands for the Drug Abuse Screening Test which was developed in 1982 and is still used today.7 It is a 28-item self- reporting questionnaire that is similar to the items on the Michigan Alcoholism Screening Test (MAST). The DAST questionnaire typically looks like this:7
Answer yes or no to the following questions:
Questions About Your Substance Use
1. Have you used drugs other than those required for medical reasons?
2. Have you abused prescription drugs?
3. Do you abuse more than one drug at a time?
4. Can you get through the week without using drugs (other than those required for medical reasons)?
5. Are you always able to stop using drugs when you want to?
6. Do you abuse drugs on a continuous basis?
7. Do you try to limit your drug use to certain situations?
8. Have you had “blackouts” or “flashbacks” as a result of drug use?
9. Do you ever feel bad about your drug abuse?
Questions About Your Relationships and Work
10. Does your spouse (or parents) ever complain about your involvement with drugs?
11. Do your friends or relatives know or suspect you abuse drugs?
12. Has drug abuse ever created problems between you and your spouse?
13. Has any family member ever sought help for problems related to your drug use?
14. Have you ever lost friends because of your use of drugs?
15. Have you ever neglected your family or missed work because of your use of drugs?
16. Have you ever been in trouble at work because of drug abuse?
17. Have you ever lost a job because of drug abuse?
18. Have you gotten into fights when under the influence of drugs?
Questions About Effects of Substance Use
19. Have you ever been arrested because of unusual behavior while under the influence of drugs?
20. Have you ever been arrested for driving while under the influence of drugs?
21. Have you engaged in illegal activities to obtain drugs?
22. Have you ever been arrested for possession of illegal drugs?
23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake?
24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?
Questions About Trying to Stop
25. Have you ever gone to anyone for help for a drug problem?
26. Have you ever been in a hospital for medical problems related to your drug use?
27. Have you ever been involved in a treatment program specifically related to drug use?
28. Have you been treated as an outpatient for problems related to drug abuse?
Each “yes” response is scored 1 point except questions 4,5 and 7 of the first section for which a “no” answer is 1 point.7 Cut-off scores for the identification of substance use disorders range from 6 points to 11 points, but generally, anything over 12 points would be a considered a substance abuse problem.7
DAST-A stands for Drug Abuse Screening Test- Adolescent and is identical to DAST with a few changes to the wording to make it suitable for adolescents. Anything over 6 points here would be considered problematic.
The Fagerstrom Test is a test for nicotine dependence. It is a questionnaire comprised of the following 6 questions:8
How soon after waking do you smoke your first cigarette?
- Within 5 minutes (3 points)
- 6-30 minutes (2 points)
- 31-60 minutes (1 point)
- After 60 minutes (0 points)
Do you find it difficult to refrain from smoking in places where it is forbidden?
- Yes (1 point)
- No (0 points)
Which cigarette would you hate to give up?
- The first in the morning (1 point)
- Any other (0 points)
How many cigarettes a day do you smoke?
- 10 or less (0 points)
- 11-20 (1 point)
- 21-30 (2 points)
- 31 or more (3 points)
Do you smoke more frequently in the morning?
- Yes (1 point)
- No (0 points)
Do you smoke even if you are sick in bed most of the day?
- Yes (1 point)
- No (0 points)
- 1-2 points = low dependence
- 3-4 points = low to moderate dependence
- 5-7 points = moderate dependence
- 8+ = high dependence
TWEAK is a screening tool used to identify pregnant women who are at risk for alcohol use. There are 5 items on the TWEAK questionnaire:2
How many drinks does it take for you to feel high? (Tolerance) (2 or more drinks = 2 points)
Does your partner (or do your parents) ever Worry or complain about your drinking? (yes = 2 points)
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye opener) (yes = 1 point)
Have you ever Awakened the morning after some drinking the night before and found that you could not remember part of the evening? (yes = 1 point)
Have you ever felt that you ought to K/cut down on your drinking? (yes = 1 point)
2 or more points indicates that there might be a risk of drinking during pregnancy. This would require further evaluation to monitor a patients drinking habits throughout her pregnancy.2
Prescription drugs for non-medical purposes
The possible answers are:
Once or twice
If a patient identifies that they use any of the substances, further screening will be recommended. Typically, the additional screening will be done using ASSIST, which determines which substances are used and how frequently.
Other Ways to Screen for Substance Use Disorder
Are There Physically Observable Signs?
The substance use disorder evaluation tools discussed above mainly look into habits and behaviors surrounding use, frequency of use, personal history, symptoms, and more; however, there are also physical indicators of substance abuse that can be observed by healthcare physicians. These include:
Excessive sniffing/runny nose
Lack of personal hygiene
Loss of appetite/change in eating habits
Unusual body odor
Scabs or marks on the skin
Lab Evaluations to Detect Substance Use Disorder?
Laboratory testing can be used in the identification of alcohol and substance use; however, their usefulness is limited. Laboratory testing may indicate the presence of a drug or identify tolerance but cannot measure the severity of a disease.10 That being said, laboratory testing may be used in conjunction with other forms of evaluation to paint a full picture of someone’s health status. Laboratory testing includes:10
Routine laboratory screening such as liver function tests, complete blood count, vitamin B12, and folate levels might raise red flags for substance use and require further evaluation.
Blood alcohol levels, breathalyzer tests, urine drug tests, and hair and saliva analysis indicate the presence of alcohol or substances.
Blood, urine, and saliva testing can also be used in the process of treatment to establish structure and limits, which help patients to follow guidelines, establish self-control, and to monitor patient use.
Using a Patient’s History to Find Substance Use Disorder
More often than not, a patient’s personal history will give a large indication as to why they began using substances in the first place. Whether a patient has family with substance use disorders and therefore is genetically at a higher risk of developing a dependence on drugs, or a person has previous mental illnesses such as depression or anxiety where they are using substances to self-medicate, a persons’ history can help physicians to determine whether a patients’ substance use is problematic or not. According to the National Council on Alcohol and Drug Dependence, a patient with a family history of substance use disorders is twice as likely to develop one themselves. Additionally, patients who have suffered from childhood abuse or trauma, or have pre-existing mental illnesses are at higher risk of developing substance use disorders themselves. Because family medical history and previous mental health issues are risk factors for substance abuse, a physician needs to know about a patients’ history to be able to diagnose substance use disorder.
Risk Factors for Addiction:
- Family History
- Abusive or Traumatic Childhood
- Pre-Existing Mental Illness
In adolescents, risk factors for mental health and substance abuse include low self-esteem, academic problems, loneliness, depression, and a desire for social acceptance. When it comes to adolescents and young adults, inquiring about their school life and home life is essential in discovering why a patient might have started using in the first place.
Adolescent Risk Factors for Substance Abuse:
- Low Self-Esteem
- Academic Problems
- Desire for Social Acceptance
Motivating a Patient to Recover from Substance Use Disorder
What is a Brief Intervention? And When Is It Used?
A brief intervention is a very short conversation that lasts anywhere between 5-30 minutes and is intended to motivate patients who present with risky substance use to change their behavior.11 A brief intervention is not a method of treatment to be used for people with serious substance use disorders but rather, it is the first point of contact for patients who have developed substance dependence.11
A brief intervention will occur in a primary care setting and might involve your doctor simply asking questions about your use, and discussing whether you should seek further treatment.11 Brief interventions might also be used to encourage people with substance use disorders to accept more intensive treatment programs or to be referred to specialized treatment facilities.11 Essentially, brief interventions are not methods of treatment, but rather the stage before treatment where your doctor might encourage you to seek change and to seek treatment if necessary.
Is a Patient is Ready to Change?
For substance use treatment to be effective, a patient has to be ready and willing to make changes in their life. If they are not at the stage where they are ready to make lifestyle changes and fully commit to treatment, it is not going to be effective.
A necessary skill of a healthcare provider or a psychotherapist is to be able to motivate a patient to want to make changes for their own benefit, rather than dictating what they must do. Substance use disorders are delicate matters that are often intertwined with mental health issues.
While it might seem simple to people who have not struggled with dependence to simply stop using substances, addiction is far from that simple. Even a desire to change is not always enough to stop using substances, particularly when your body has developed a dependence on drugs and craves them.
Motivation Might Not Be Enough
Additionally, a motivation to change your lifestyle is not always enough to make a patient want to partake in treatment. Patients might not want to participate in substance use treatment for a variety of reasons, including prior unsuccessful attempts. Remember, substance use treatment does not work in the same way for everyone, and it can make many people feel trapped.
To determine whether a patient is ready for treatment, William Miller and J. Scott Tonigan developed the States of Change Readiness and Treatment Eagerness Scale (SOCRATES) in 1996. SOCRATES is a 19 item questionnaire that is broken down into 3 main sections: recognition, ambivalence, and taking steps. The questionnaire takes about 5 minutes to administer, is typically administered in a healthcare setting, and determines a patient's readiness for treatment compared to people who are already seeking out treatment for substance use.
What is a Narcotic Contract?
A narcotic contract, also known as a medication contract, is something that is used to ensure that patients are using their medication appropriately. A narcotic contract is a written agreement between a doctor and a patient about the requirements of being prescribed opioids for the long term treatment of chronic pain.
Because opioids are so addictive, contracts are believed to decrease the number of people who develop substance use disorders. Opioid contracts might include conditions such as showing up to regular appointments, avoid requests for extra prescriptions, agreeing to take regular drug tests, and agreeing not to sell any of the medication.
One of the downfalls of narcotic contracts is that many patients will break the contracts and thus be denied further treatment, which can hinder their chances of success in treatment.
How To Deal With Resistant Patient Behaviors?
When dealing with substance use disorders, it is common for healthcare providers to encounter resistant patient behaviors. Patients who do not view their substance use as problematic or who do not wish to change their lifestyle might be resistant to the idea of change or to suggestions that they need treatment.
Many people are comfortable with their habits and lifestyles and don’t want to be told by healthcare providers that they need to make changes, even if it is for their benefit. The age-old saying that you can’t change other people, you can only change yourself, rings true here too.
Healthcare providers can’t change patients; only patients can make the changes they need to for themselves. That being said, there are some approaches and tips for dealing with resistant patient behaviors that might make it easier to motivate change in patients. Some tips are:12
Be Patient and Detached
Try not to present yourself as an expert. A patient who is resistant to treatment is unlikely to want to be told what to do and made to feel unknowledgeable.
Try to avoid dwelling on and accepting the patient's excuses for their use. While it is useful to understand why they started using substances, it is not beneficial to the patient to encourage their excuses.
Take baby steps. If you encounter resistance in a patient, slow down and start small. If seeking treatment is too big of a goal, start with something smaller such as reducing the frequency of use.
Do not argue with clients. Accept, listen to, and understand what they are telling you. Reflect back to them how they feel and suggest small changes.
Try to focus on solutions. If your patient presents you with problems and excuses, try to come up with valid and realistic solutions.
Respect the Patient
Try not to place blame on patients. While there might be many bad decisions a patient has made, there is no use in casting blame. They will only feel more defensive.
Realize that patients have the agency to make decisions for themselves. Don’t try to force anything on them.
Try to open a dialogue with a patient rather than have an interrogation where you bombard them with questions. You are more likely to succeed if your patient feels like you are just two people having a conversation.
Respect patients! A patient wants to feel heard and respected. Using substances does not make them less of a person, and they deserve the same respect as anyone else.
Try to bring out the patient’s motivation for change. Come up with good reasons together to highlight why change might be positive. If a patient can’t see any reasons for changing their behavior, why would they change? Work together to find the positive benefits of change.
How are Substance Use Disorders Treated?
There are various treatment options for different forms of substance use disorder. The first step for many substance users is a detox that should occur in a medical environment. Many substance use disorders will also require medication-assisted therapy to help combat withdrawal symptoms and help patients to refrain from using substances.
Most treatments will include counseling or therapy to help change patient behavior surrounding substance use and to learn better coping strategies and healthier lifestyle habits. Support groups such as Alcoholics Anonymous or Narcotics Anonymous may be used to help patients feel supported and understood by like-minded people. Treatment can occur at inpatient or outpatient facilities, including rehabilitation facilities.