Substance Use Disorder Evaluations

Learn About the Many SUD Assessment Tools

Author: J. Flowers Health Staff

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: 713.715.1618

What is a Substance Use Disorder?

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Substance use disorders (SUD) 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.

Addictive substances activate the brain’s reward systems, which produce feelings of pleasure, relaxation, and euphoria. The rewards felt from abusing substances are so great that people will continue to use them despite the negative consequences.

While some people are more susceptible to substance use disorders than others, everyone is at risk of developing a substance use disorder if they abuse substances.

Our J. Flowers Health Institute team utilizes its comprehensive diagnostic evaluations to identify any potential substance use disorders in order to facilitate personalized treatment.

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

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What are the Risk Factors of Substance Use Disorder?

It is important to consider the factors that may lead someone to use substances when conducting the screening. These risk factors may include:

Specific Assessment Tools

Although the DSM-5 outlines the diagnostic criteria for substance use disorders, there are more specific substance use disorder evaluation screening tools used.

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.

ASSIST Evaluation

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:

The answers to this questionnaire provide information about the level of risk associated with the patient’s 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.

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

10 Questions

The 10 questions that are typically included in an AUDIT include:³

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?

Scoring

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

AUDIT-C Evaluation

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

Answers range in point values from 0-4. A total of 4 or more points identifies 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 lives.

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.

CRAFFT Questionnaire

A typical CRAFFT questionnaire looks like this:⁵

Part A

Answer yes or no to the following questions.

Part B

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.

MAST Evaluation

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:

Questions About Family and Work

Has drinking ever created problems between you and a near relative or close friend?
Has any family member or close friend gone to anyone for help about your drinking?
Have you ever lost friends because of your drinking?
Have you ever gotten into trouble at work because of drinking?
Have you ever lost a job because of drinking?
Have you ever neglected your obligations, family, or work for two or more days in a row because you were drinking?
Do you drink before noon fairly often?

Questions About the Consequences of Your Drinking

Have you ever been told you have liver trouble, such as cirrhosis?
After heavy drinking, have you ever had delirium tremens (DTs), severe shaking, visual or auditory (hearing) hallucinations?
Have you ever gone to anyone for help with your drinking?
Have you ever been hospitalized because of drinking?
Has your drinking ever resulted in your being hospitalized in a psychiatric ward?
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?
Have you been arrested more than once for driving under the influence of alcohol?
Have you ever been arrested, or detained by an official for a few hours, because of other behavior while drinking?

MAST Scoring

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 Relationships and Work

Does your spouse (or parents) ever complain about your involvement with drugs?
Do your friends or relatives know or suspect you abuse drugs?
Has drug abuse ever created problems between you and your spouse?
Has any family member ever sought help for problems related to your drug use?
Have you ever lost friends because of your use of drugs?
Have you ever neglected your family or missed work because of your use of drugs?
Have you ever been in trouble at work because of drug abuse?
Have you ever lost a job because of drug abuse?
Have you gotten into fights when under the influence of drugs?

Questions About Family and Work

Has drinking ever created problems between you and a near relative or close friend?
Has any family member or close friend gone to anyone for help about your drinking?
Have you ever lost friends because of your drinking?
Have you ever gotten into trouble at work because of drinking?
Have you ever lost a job because of drinking?
Have you ever neglected your obligations, family, or work for two or more days in a row because you were drinking?
Do you drink before noon fairly often?

Questions About Effects of Substance Use

Have you ever been arrested because of unusual behavior while under the influence of drugs?
Have you ever been arrested for driving while under the influence of drugs?
Have you engaged in illegal activities to obtain drugs?
Have you ever been arrested for possession of illegal drugs?
Have you ever experienced withdrawal symptoms as a result of heavy drug intake?
Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

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 considered a substance abuse problem.⁷

DAST-A

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.

Fagerstrom Test

The Fagerstrom Test is a test for nicotine dependence. It is a questionnaire comprised of the following 6 questions:⁸

Scoring

1-2 points = low dependence
3-4 points = low to moderate dependence
5-7 points = moderate dependence
8+ = high dependence

TWEAK Substance Use Disorder Evaluation

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:

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 cut down on your drinking? (yes = 1 point)

NIDA Drug Screening Tool

The National Institute of Drug Abuse has a brief drug screening tool that is used to identify if a patient uses alcohol or substances.⁹ The quick screening question is:⁹

In the past year, how often have you used the following?

The possible answers are:

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:

Dilated pupils
Red eyes
Excessive sniffing/runny nose
Pale appearance
Lack of personal hygiene
Loss of appetite/change in eating habits
Weight loss
Appearing undernourished
Repetitive speech
Unusual body odor
Scabs or marks on the skin
Dental/gun problems

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 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 comes from a 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 person’s 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 patient’s history to be able to diagnose substance use disorder.

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.

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.

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 Ready to Change?

For substance abuse 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, no amount of treatment will be sustainable for them.

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 other mental health challenges.

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

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 the wrong kind can make many people feel trapped.

SOCRATES

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, avoiding 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.

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 include: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 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.

If you would like additional support during your recovery, know that our highly qualified team of experts at J. Flowers Health Institute is here to support you and provide you with the guidance you need for sustainable wellness and sobriety.

Substance Use Disorder Evaluations

Comprehensive Diagnostic Evaluations at J. Flowers Health Institute

What is a Substance Use Disorder?

Table of Contents

Reach Out to Learn More

What are the Symptoms of Substance Use Disorder?

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What are the Risk Factors of Substance Use Disorder?

Specific Assessment Tools

CAGE Substance Use Disorder Evaluation

ASSIST Evaluation

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 8

What Substances Does ASSIST Screen For?

AUDIT Substance Use Disorder Evaluation

10 Questions

Scoring

AUDIT-C Evaluation

CRAFFT Substance Use Disorder Evaluation

CRAFFT Questionnaire

Part A

Part B

CRAFFT Screening Tool for Adolescent Substance Abuse

MAST Evaluation

Question Directed at Your Drinking

Questions About Family and Work

Questions About the Consequences of Your Drinking

MAST Scoring

DAST Substance Use Disorder Evaluation

Questions About Your Relationships and Work

Questions About Family and Work

Questions About Effects of Substance Use

Questions About Trying to Stop

DAST-A

Fagerstrom Test

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Scoring

TWEAK Substance Use Disorder Evaluation

NIDA Drug Screening Tool

Other Ways to Screen for Substance Use Disorder

Are There Physically Observable Signs?

Lab Evaluations to Detect Substance Use Disorder?

Using a Patient’s History to Find Substance Use Disorder

Risk Factors for Addiction:

Adolescent Risk Factors for Substance Abuse:

Motivating a Patient to Recover from Substance Use Disorder

What is a Brief Intervention and When Is It Used?

Is a Patient Ready to Change?

Motivation Might Not Be Enough

SOCRATES

What is a Narcotic Contract?

How To Deal With Resistant Patient Behaviors?

Be Patient and Detached

Respect the Patient

How are Substance Use Disorders Treated?

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