Asi lite cf

Addiction Severity Index Lite - CF
Thomas McLellan, Ph.D.
HOLLINGSHEAD CATEGORIES:
John Cacciola, Ph.D.
1. Higher execs, major professionals, owners of large businesses. 2. Business managers if medium sized businesses, lesser professions, i.e., Deni Carise, Ph.D.
nurses, opticians, pharmacists, social workers, teachers. Thomas H. Coyne, MSW
3. Administrative personnel, managers, minor professionals, Remember: This is an interview, not a test
owners/proprietors of small businesses, i.e., bakery, car dealership, engraving business, plumbing business, florist, decorator, actor, reporter, ≈Item numbers circled are to be asked at follow-up.≈
≈Items with an asterisk* are cumulative and should be
4. Clerical and sales, technicians, small businesses (bank teller, bookkeeper, rephrased at follow-up.≈
clerk, draftsman, timekeeper, secretary). Items in a double border gray box are questions for the interviewer.
5. Skilled manual - usually having had training (baker, barber, brakeman, Do not ask these questions of the client.≈
chef, electrician, fireman, lineman, machinist, mechanic, paperhanger, painter, repairman, tailor, welder, policeman, plumber). 6. Semi-skilled (hospital aide, painter, bartender, bus driver, cutter, cook, INTRODUCING THE ASI: Seven potential problem areas: Medical,
drill press, garage guard, checker, waiter, spot welder, machine operator). Employment/Support Status, Alcohol, Drug, Legal, Family/Social, and 7. Unskilled (attendant, janitor, construction helper, unspecified labor, Psychological. All clients receive this same standard interview. All There are two time periods we will discuss: LIST OF COMMONLY USED DRUGS:
Patient Rating Scale: Patient input is important. For each area, I will ask
you to use this scale to let me know how bothered you have been by any problems in each section. I will also ask you how important treatment is for Pain killers = Morphine, Dilaudid, Demerol, Percocet, Darvon, Talwin, Codeine, Tylenol 2,3,4, Nembutal, Seconal, Tuinal, Amytal, Pentobarbital, Benzodiazepines = Valium, Librium, Ativan, Serax Tranxene, Dalmane, Halcion, Xanax, Miltown, If you are uncomfortable giving an answer, then don't answer. Cocaine Crystal, Free-Base Cocaine or Crack, and Please do not give inaccurate information!
Monster, Crank, Benzedrine, Dexedrine, Ritalin, Preludin, Methamphetamine, Speed, Ice, Crystal INTERVIEWER INSTRUCTIONS:
LSD (Acid), Mescaline, Psilocybin (Mushrooms), Peyote, Green, PCP (Phencyclidine), Angel Dust, Ecstacy 2. Make plenty of Comments (if another person reads this ASI, they should Nitrous Oxide (Whippits), Amyl Nitrite (Poppers), have a relatively complete picture of the client's perceptions ofhis/her 4. Terminate interview if client misrepresents two or more sections. 5. When noting comments, please write the question number. 6. Tutorial/clarification notes are preceded with "•". ALCOHOL/DRUG USE INSTRUCTIONS:
The following questions look at two time periods: the past 30 days and lifetime.
HALF TIME RULE:
If a question asks the number of months, Lifetime refers to the time prior to the last 30 days. However if the client has been round up periods of 14 days or more to 1 incarcerated for more than 1 year, you would only gather lifetime information, unless the client admits to significant alcohol /drug use during incarceration. This guideline only applies to the Alcohol/Drug Section. 30 day questions only require the number of days used. CONFIDENCE RATINGS:
Lifetime use is asked to determine extended periods of use. Regular use = 3+ times per week, binges, or problematic irregular use in which normal activities are compromised. Alcohol to intoxication does not necessarily mean "drunk", use the words felt the effects", “got a buzz”, “high”, etc. instead of intoxication. Misrepresentation = overt contradiction in As a rule of thumb, 5+ drinks in one setting, or within a brief period of Probe and make plenty of comments!
“How to ask these questions:
→ "How many days in the past 30 have you used.? → "How many years in your life have you regularly used.?" NEW BEGINNINGS ADDICTION & RECOVERY CENTER Addiction Severity Index Lite - Training Version
GENERAL INFORMATION
__________________________________________________
__________________________________________________
G2. SS No. : - -
__________________________________________________
______________________________________(____)______
G4. Date of Admission: / /
G5. Date of Interview: / /
G17. Of what race do you consider yourself? 1. White (not Hisp) 5. Asian/Pacific 9. Other Hispanic 2. Black (not Hisp) 6. Hispanic-Mexican 2. Telephone (Intake ASI must be in person) 3. American Indian 7. Hispanic-Puerto Rican G18. Do you have a religious preference? G19. Have you been in a controlled environment in •A place, theoretically, without access to drugs/alcohol. •"NN" if Question G19 is No. Refers to total number of days detained in the past 30 days. (Clinical/Training Version)
MEDICAL STATUS
MEDICAL COMMENTS
(Include question number with your notes) M1.∗ How many times in your life have you been __________________________________________________
• Include O.D.'s and D.T.'s. Exclude detox, alcohol/drug, psychiatric treatment and childbirth (if no complications). Enter the __________________________________________________
number of overnight hospitalizations for medical problems.
__________________________________________________
__________________________________________________
__________________________________________________
• If "Yes", specify in comments.
• A chronic medical condition is a serious physical __________________________________________________
condition that requires regular care, (i.e., medication, dietary restriction) preventing full advantage of their abilities. __________________________________________________
__________________________________________________
__________________________________________________
• If Yes, specify in comments.
• Medication prescribed by a MD for medical conditions; not
psychiatric medicines. Include medicines prescribed whether or not
__________________________________________________
the patient is currently taking them. The intent is to verify chronic __________________________________________________
__________________________________________________
• If Yes, specify in comments.
__________________________________________________
• Include Workers' compensation, exclude psychiatric disability. __________________________________________________
__________________________________________________
• Do not include ailments directly caused by drugs/alcohol. • Include flu, colds, etc. Include serious ailments related to drugs/alcohol, which would continue even if the patient were abstinent __________________________________________________
(e.g., cirrhosis of liver, abscesses from needles, etc.). __________________________________________________
For Questions M7 & M8, ask the patient to use the Patient Rating scale.
M7. How troubled or bothered have you been by __________________________________________________
these medical problems in the past 30 days? • Restrict response to problem days of Question M6. __________________________________________________
M8. How important to you now is treatment for __________________________________________________
• Refers to the need for new or additional medical treatment by the patient.
__________________________________________________
__________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
__________________________________________________
__________________________________________________
__________________________________________________
EMPLOYMENT/SUPPORT STATUS
EMPLOYMENT/SUPPORT COMMENTS
(Include question number with your notes) __________________________________________________
E2.∗ Training or Technical education completed: __________________________________________________
• Formal/organized training only. For military training, only include training that can be used in civilian life, Months __________________________________________________
__________________________________________________
E4. Do you have a valid driver's license? __________________________________________________
• Valid license; not suspended/revoked. E5. Do you have an automobile available? __________________________________________________
• If answer to E4 is "No", then E5 must be "No". 0 - No 1 - Yes
Does not require ownership, only requires __________________________________________________
__________________________________________________
E6. How long was your longest full time job? __________________________________________________
__________________________________________________
__________________________________________________
(specify) ______________________________ __________________________________________________
(use Hollingshead Categories Reference Sheet) __________________________________________________
E9 Does someone contribute the majority of __________________________________________________
__________________________________________________
__________________________________________________
E10. Usual employment pattern, past three years? 1. Full time (35+ hours) 5. Service 2. Part time (regular hours) 6. Retired/Disability __________________________________________________
3. Part time (irregular hours) 7. Unemployed __________________________________________________
• Answer should represent the majority of the last 3 years, not just the most recent selection. If there are equal times for more than one category, select that which best represents more current situation. __________________________________________________
__________________________________________________
E11. How many days were you paid for working __________________________________________________
• Include "under the table" work, paid sick days and vacation. __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
EMPLOYMENT/SUPPORT (cont.)
For questions E12-17: How much money did you receive from
EMPLOYMENT/SUPPORT COMMENTS
the following sources in the past 30 days?
(Include question number with your notes) __________________________________________________
• Net or "take home" pay, include any __________________________________________________
__________________________________________________
• Include food stamps, transportation money __________________________________________________
__________________________________________________
__________________________________________________
• Include disability, pensions, retirement, veteran's benefits, SSI & workers' compensation. __________________________________________________
clothing), include unreliable sources of income __________________________________________________
(e.g. gambling). Record cash payments only,
include windfalls (unexpected), money from __________________________________________________
loans, gambling, inheritance, tax returns, etc.). __________________________________________________
•Cash obtained from drug dealing,
stealing, fencing stolen goods, gambling, prostitution, etc. Do not attempt to convert
__________________________________________________
__________________________________________________
the majority of their food, shelter, etc.? __________________________________________________
• Must be regularly depending on patient, do include alimony/child support, do not include the patient or self-supporting spouse, etc. __________________________________________________
__________________________________________________
• Include inability to find work, if they are actively looking for work, or problems with present job in which that job is jeopardized. __________________________________________________
For Question E20, ask the patient to use the Patient Rating scale.
__________________________________________________
E20. How troubled or bothered have you been by these employment problems in the past 30 days? __________________________________________________
• If the patient has been incarcerated or detained during the past 30 days, they cannot have employment problems. __________________________________________________
E21. How important to you now is counseling for __________________________________________________
• The patient's ratings in Questions E20-21 refer to Question E19. • Stress help in finding or preparing for a job, not giving them a job. __________________________________________________
__________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
__________________________________________________
__________________________________________________
E24. Patient's inability to understand? 0-No 1-Yes __________________________________________________
__________________________________________________
__________________________________________________
ALCOHOL/DRUGS
ALCOHOL/DRUGS COMMENTS
(Include question number with your notes) Route of Administration Types:
1. Oral 2. Nasal 3. Smoking 4. Non-IV injection 5. IV __________________________________________________
Note the usual or most recent route. For more than one route, choose the most severe. The routes are listed from least severe to most severe. __________________________________________________
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__________________________________________________
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__________________________________________________

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D17. How many times have you had Alcohol DT's? • Delirium Tremens (DT's): Occur 24-48 hours after last drink, or
significant decrease in alcohol intake, shaking, severe disorientation, __________________________________________________
fever, , hallucinations, they usually require medical attention. ALCOHOL/DRUGS (cont.)
ALCOHOL/DRUGS COMMENTS
How many times in your life have you been treated for : (Include question number with your notes) __________________________________________________

__________________________________________________
• Include detoxification, halfway houses, in/outpatient counseling, and AA or NA (if 3+ meetings within one month period). __________________________________________________
__________________________________________________
__________________________________________________
• If D19 = "00", then question D21 is "NN" If D20 = ‘00’, then question D22 is “NN” __________________________________________________
How much money would you say you spent during the past __________________________________________________

__________________________________________________
__________________________________________________
• Only count actual money spent. What is the financial burden caused by
__________________________________________________
D25. How many days have you been treated as an outpatient for alcohol or drugs in the __________________________________________________
__________________________________________________
For Questions D28-D31, ask the patient to use the Patient Rating scale.
The patient is rating the need for additional substance abuse treatment.
__________________________________________________
How many days in the past 30 have you experienced:
__________________________________________________
How troubled or bothered have you been in the past 30 days by __________________________________________________

__________________________________________________
How important to you now is treatment for these: __________________________________________________

__________________________________________________
How many days in the past 30 have you experienced:
__________________________________________________
• Include only: Craving, withdrawal symptoms, __________________________________________________
disturbing effects of use, or wanting to stop and being unable to. How troubled or bothered have you been in the past 30 days by __________________________________________________
__________________________________________________

How important to you now is treatment for these: __________________________________________________

__________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
D35. Patient's inability to understand? 0-No 1-Yes LEGAL STATUS
LEGAL COMMENTS
L1. Was this admission prompted or suggested by the (Include question number with your notes) • Judge, probation/parole officer, etc. __________________________________________________
• Note duration and level in comments. __________________________________________________
How many times in your life have you been arrested and
__________________________________________________
charged with the following:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
• Include total number of counts, not just convictions. Do not include __________________________________________________
juvenile (pre-age 18) crimes, unless they were charged as an adult. __________________________________________________
L17∗ How many of these charges resulted __________________________________________________
• If L03-16 = 00, then question L17 = "NN". • Do not include misdemeanor offenses from questions L18-20 below. __________________________________________________
• Convictions include fines, probation, incarcerations, suspended __________________________________________________
How many times in your life have you been charged with
the following:
__________________________________________________

__________________________________________________
__________________________________________________
__________________________________________________
• Moving violations: speeding, reckless driving, __________________________________________________
L21∗ How many months were you incarcerated __________________________________________________
• If incarcerated 2 weeks or more, round this up to 1 month. List total number of months incarcerated. __________________________________________________
__________________________________________________
__________________________________________________
• Use the number of the type of crime committed: 03-16 __________________________________________________
• Refers to Q. L24. If more than one, choose most severe. • Don't include civil cases, unless a criminal offense is involved. __________________________________________________
__________________________________________________
• Include being arrested and released on the same day. __________________________________________________
__________________________________________________
LEGAL STATUS (cont.)
LEGAL COMMENTS
(Include question number with your notes) you engaged in illegal activities for profit? • Exclude simple drug possession. Include drug dealing, prostitution, __________________________________________________
selling stolen goods, etc. May be cross checked with Question E17 under Employment/Family Support Section. __________________________________________________
__________________________________________________
For Questions L28-29, ask the patient to use the Patient Rating scale.
L28. How serious do you feel your present legal problems __________________________________________________
__________________________________________________
L29. How important to you now is counseling __________________________________________________
• Patient is rating a need for additional referral to legal counsel
__________________________________________________
__________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
__________________________________________________
__________________________________________________
L32. Patient's inability to understand? 0 - No 1 - Yes __________________________________________________
FAMILY/SOCIAL RELATIONSHIPS
FAMILY/SOCIAL COMMENTS
(Include question number with your notes) __________________________________________________
2-Remarried 4-Separated 6-Never Married • Common-law marriage = 1. Specify in comments. __________________________________________________
F3. Are you satisfied with this situation? • Satisfied = generally liking the situation. - Refers to Questions F1 & F2. __________________________________________________
F4.∗ Usual living arrangements (past 3 years): __________________________________________________
__________________________________________________
__________________________________________________
Choose arrangements most representative of the past 3 years. If there is an even split in time between these arrangements, choose the most recent arrangement. __________________________________________________
F6. Are you satisfied with these arrangements? __________________________________________________
Do you live with anyone who:

__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
• If a girlfriend/boyfriend is considered as family by patient, then they must refer to them as family throughout this section, not a friend. __________________________________________________
F10. Are you satisfied with spending your free time __________________________________________________
• A satisfied response must indicate that the person generally likes the situation. Referring to Question F9. __________________________________________________
Have you had significant periods in which you have
experienced serious problems getting along with:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
• "Serious problems" mean those that endangered the relationship. __________________________________________________
• A "problem" requires contact of some sort, either by telephone or in person. __________________________________________________
Did anyone abuse you?
__________________________________________________
__________________________________________________
FAMILY/SOCIAL (cont.)
FAMILY/SOCIAL COMMENTS
(Include question number with your notes) How many days in the past 30 have you had serious
conflicts:
__________________________________________________

__________________________________________________
For Questions F32-34, ask the patient to use the Patient Rating scale.

__________________________________________________
How troubled or bothered have you been in the past 30
__________________________________________________
__________________________________________________
FHow important to you now is treatment or counseling for
__________________________________________________
• Patient is rating his/her need for counseling for family __________________________________________________
problems, not whether the family would be willing to attend.
How many days in the past 30 have you had serious
__________________________________________________
conflicts:

__________________________________________________
F31. With other people (excluding family)? For Questions F33-35, ask the patient to use the Patient Rating scale.
__________________________________________________
How troubled or bothered have you been in the past 30
__________________________________________________

__________________________________________________
How important to you now is treatment or counseling for
__________________________________________________
__________________________________________________
• Include patient's need to seek treatment for such social problems as loneliness, inability to socialize, and __________________________________________________
dissatisfaction with friends. Patient rating should refer to dissatisfaction, conflicts, or other serious problems. __________________________________________________
__________________________________________________
CONFIDENCE RATING
Is the above information significantly distorted by:
__________________________________________________
__________________________________________________
F38. Patient's inability to understand? 0-No 1-Yes __________________________________________________

__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
PSYCHIATRIC STATUS
How many times have you been treated for any
PSYCHIATRIC STATUS COMMENTS
psychological or emotional problems:
(Include question number with your comments) P1.∗ In a hospital or inpatient setting? __________________________________________________
• Do not include substance abuse, employment, or family counseling. __________________________________________________
Treatment episode = a series of more or less continuous visits or treatment days, not the number of visits or treatment days. • Enter diagnosis in comments if known. __________________________________________________
P3. Do you receive a pension for a psychiatric disability? __________________________________________________
__________________________________________________
Have you had a significant period of time (that was not a
direct result of alcohol/drug use) in which you have:
__________________________________________________
__________________________________________________
__________________________________________________
interest, difficulty with daily function? P5. Experienced serious anxiety/ tension, __________________________________________________

uptight, unreasonably worried, inability to feel relaxed? __________________________________________________
P6. Experienced hallucinations-saw things __________________________________________________
__________________________________________________
__________________________________________________
For Items P8-10, Patient can have been under the influence of alcohol/drugs.
P8. Experienced trouble controlling violent behavior __________________________________________________
including episodes of rage, or violence? P9. Experienced serious thoughts of suicide? __________________________________________________
• Patient seriously considered a plan for taking __________________________________________________
• Include actual suicidal gestures or attempts. __________________________________________________
__________________________________________________
• Prescribed for the patient by MD. Record "Yes" if a medication was prescribed even if the patient is not taking it. __________________________________________________
P12. How many days in the past 30 have you experienced __________________________________________________
these psychological or emotional problems? • This refers to problems noted in Questions P4-P10. __________________________________________________
For Questions P13-P14, ask the patient to use the Patient Rating scale
__________________________________________________
P13. How much have you been troubled or bothered by these psychological or emotional problems in the past 30 days? __________________________________________________
• Patient should be rating the problem days from Question P12. P14. How important to you now is treatment for __________________________________________________
these psychological or emotional problems? CONFIDENCE RATING
Is the above information significantly distorted by:
P23. Patient's inability to understand? 0-No 1-Yes

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