Asi clinical training

Addiction Severity Index 5th Edition
A. Thomas McLellan, Ph.D.
HOLLINGSHEAD CATEGORIES:
Deni Carise, Ph.D.
1. Higher execs, major professionals, owners of large businesses. Thomas H. Coyne, MSW
2. Business managers if medium sized businesses, lesser professions, i.e., nurses, opticians, pharmacists, social workers, teachers. Remember: This is an interview, not a test
3. Administrative personnel, managers, minor professionals, owners/proprietors of small businesses, i.e., bakery, car dealership, ≈Item numbers circled are to be asked at follow-up.≈
engraving business, plumbing business, florist, decorator, actor, reporter, ≈Items with an asterisk are cumulative and should be rephrased at
follow-up.≈
4. Clerical and sales, technicians, small businesses (bank teller, bookkeeper, clerk, draftsperson, timekeeper, secretary). 5. Skilled manual - usually having had training (baker, barber, brakeperson, chef, electrician, fireman, machinist, mechanic, paperhanger, painter, INTRODUCING THE ASI: Introduce and explain the seven potential
repairperson, tailor, welder, police, plumber). problem areas: Medical, Employment/Support Status, Alcohol, Drug, 6. Semi-skilled (hospital aide, painter, bartender, bus driver, cutter, cook, Legal, Family/Social, and Psychiatric. All clients receive this same drill press, garage guard, checker, waiter, spot welder, machine operator). standard interview. All information gathered is confidential; explain what 7. Unskilled (attendant, janitor, construction helper, unspecified labor, that means in your facility; who has access to the information and the 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 Pain killers = Morphine, Dilaudid, Demerol, problems in each section. I will also ask you how important treatment is for Percocet, Darvon, Talwin, Codeine, Tylenol 2,3,4, Nembutal, Seconal, Tuinal, Amytal, Pentobarbital, Benzodiazepines = Valium, Librium, Ativan, Serax Tranxene, Dalmane, Halcion, Xanax, Miltown, Cocaine Crystal, Free-Base Cocaine or Crack, and Inform the client that he/she has the right to refuse to answer any question. If the client is uncomfortable or feels it is too personal or painful to give an Monster, Crank, Benzedrine, Dexedrine, Ritalin, answer, instruct the client not to answer. Explain the benefits and Preludin, Methamphetamine, Speed, Ice, Crystal advantages of answering as many questions as possible in terms of developing a comprehensive and effective treatment plan to help them. LSD (Acid), Mescaline, Psilocybin (Mushrooms), Peyote, Green, PCP (Phencyclidine), Angel Dust, Ecstacy Please try not give inaccurate information!
Nitrous Oxide (Whippits), Amyl Nitrite (Poppers), INTERVIEWER INSTRUCTIONS:
2. Make plenty of Comments (if another person reads this ASI, they should have a relatively complete picture of the client's perceptions of his/her ALCOHOL/DRUG USE INSTRUCTIONS:
4. Terminate interview if client misrepresents two or more sections. The following questions refer to two time periods: the past 30 days and lifetime. 5. When noting comments, please write the question number. Lifetime refers to the time prior to the last 30 days. 30 day questions only require the number of days used. 6. Tutorial/clarification notes are preceded with "•". Lifetime use is asked to determine extended periods of use. Regular use = 3 or more times per week, binges, or problematic HALF TIME RULE:
If a question asks the number of months, irregular use in which normal activities are compromised. round up periods of 14 days or more to 1 Alcohol to intoxication does not necessarily mean "drunk", use the words “to feel or felt the effects", “got a buzz”, “high”, etc. instead of intoxication. As a rule, 3 or more drinks in one sitting, or 5 or more CONFIDENCE RATINGS:
→ “How many days in the past 30 have you used.?”
→ "How many years in your life have you regularly used.?" Misrepresentation = overt contradiction in Probe, cross-check and make plenty of comments!
Addiction Severity Index, Fifth Edition
GENERAL INFORMATION
(Clinical/Training Version)
ADDITIONAL TEST RESULTS
_________________________
G2. SS No. : - -
_________________________
G4. Date of Admission / /
_________________________
G5. Date of Interview: / /
_________________________
G6 Time Begun: (Hour: Minutes) :
_________________________
G7. Time Ended: (Hour:Minutes) :
_________________________
_________________________
_________________________
2. Telephone (Intake ASI must be in person) _________________________
SEVERITY PROFILE
PROBLEMS
______________________________________________________
______________________________________________________
______________________________________________________
____________________________________(____)____________
GENERAL INFORMATION COMMENTS
(Include the question number with your notes) ______________________________________________________
G14. How long have you lived at this /
______________________________________________________
______________________________________________________

______________________________________________________
G16. Date of birth: (Month/Day/Year) / /
G17. Of what race do you consider yourself? ______________________________________________________
2. Black (not Hisp) 6. Hispanic-Mexican ______________________________________________________
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. MEDICAL STATUS
MEDICAL COMMENTS
M1. ∗ How many times in your life have you been (Include question number with your notes) • 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 no hospitalizations in Question M1, then this is coded "NN". ______________________________________________________
problems which continue to interfere 0 -No 1 - Yes ______________________________________________________
• 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 ______________________________________________________
M5. Do you receive a pension for a physical disability? ______________________________________________________
• If Yes, specify in comments.
• Include Workers' compensation, exclude psychiatric disability. ______________________________________________________
______________________________________________________
______________________________________________________
• 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 ______________________________________________________
• If client is currently receiving medical treatment, refer to the need for additional medical treatment by the patient.
______________________________________________________
INTERVIEWER SEVERITY RATING
______________________________________________________
M9. How would you rate the patient's need for ______________________________________________________
Refers to the patient's need for additional medical treatment.
______________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
______________________________________________________
______________________________________________________
______________________________________________________
EMPLOYMENT/SUPPORT STATUS
EMPLOYMENT/SUPPORT COMMENTS
(Include question number with your notes) • Include formal education only. Yrs. Mos. _____________________________________________________
E2.∗ Training or Technical education completed: _____________________________________________________
• Formal/organized training only. For military training, only include training that can be used in civilian life _____________________________________________________
_____________________________________________________
_____________________________________________________
• Employable, transferable skill acquired through training. • If "Yes" (specify) _________________________ _____________________________________________________
_____________________________________________________
E4. Do you have a valid driver's license? • Valid license; not suspended/revoked. _____________________________________________________
E5. Do you have an automobile available for use? • If answer toE4 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) _____________________________________________________
_____________________________________________________
_____________________________________________________
• Is patient receiving any regular support (i.e., cash, food, housing) from family/friend. Include spouse's contribution; exclude support by an institution. _____________________________________________________
_____________________________________________________
• If E8 is "No", then E9 is "N" . _____________________________________________________
E10. Usual employment pattern, past three years? _____________________________________________________
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 the current situation. _____________________________________________________
E11. How many days were you paid for working _____________________________________________________
_____________________________________________________
Include "under the table" work, paid sick days and vacation. EMPLOYMENT/SUPPORT (cont.)
EMPLOYMENT/SUPPORT COMMENTS
(Include question number with your notes) For questions E12-17: How much money did you receive from the
following sources in the past 30 days?
______________________________________________________
______________________________________________________
• 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. Record cash payments only,
______________________________________________________
include windfalls (unexpected), money from loans, legal gambling, inheritance, tax returns, etc.). ______________________________________________________
______________________________________________________
•Cash obtained from drug dealing,
stealing, fencing stolen goods, illegal 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 Questions E20 & E21, 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. ______________________________________________________
In that case an "N" response is indicated. E21. How important to you now is counseling for ______________________________________________________
• Stress help in finding or preparing for a job, not giving them a job. ______________________________________________________
INTERVIEWER SEVERITY RATING
______________________________________________________
E22. How would you rate the patient's need ______________________________________________________
CONFIDENCE RATINGS
______________________________________________________
Is the above information significantly distorted by:
______________________________________________________
______________________________________________________
ALCOHOL/DRUGS
ALCOHOL/DRUGS COMMENTS
Route of Administration Types:
(Include question number with your notes) 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. _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
D14. According to the interviewer, which _____________________________________________________
• Interviewer should determine the major drug or drugs of _____________________________________________________
abuse. Code the number next to the drug in questions 01-12, or "00" = no problem, "15" = alcohol & one or more drugs, "16" = more than one drug but no alcohol. Ask patient when not clear. _____________________________________________________
D15. How long was your last period of voluntary _____________________________________________________
• Last attempt of at least one month, not necessarily _____________________________________________________
the longest. Periods of hospitalization/incarceration do not count.
Periods of antabuse, methadone, or naltrexone use during abstinence _____________________________________________________
do count.
•”00” = never abstinent
_____________________________________________________
_____________________________________________________
• If D15 = “00”, then D16 = “NN”. _____________________________________________________
_____________________________________________________
• 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. _____________________________________________________
_____________________________________________________
• Overdoses (OD): Requires intervention by someone to
recover, not simply sleeping it off, include suicide attempts by OD. _____________________________________________________
ALCOHOL/DRUGS (cont.)
How many times in your life have you been treated for : INTERVIEWER RATING
How would you rate the patient's need for treatment for: •Include detoxification, halfway houses, in/outpatient counseling, and AA (if 3+ meetings within one month period). How much would you say you spent during the past 30 days on: CONFIDENCE RATINGS
Is the above information significantly distorted by:
How many times in your life have you been treated for : • Include detoxification, halfway houses, in/outpatient counseling, ALCOHOL/DRUGS COMMENTS
and NA (if 3+ meetings within one month period). (Include question number with your notes) ______________________________________________________
• If D19 = "00", then question D21 is "NN" ______________________________________________________
If D20 = ‘00’, then question D22 is “NN” How much would you say you spent during the past 30 ______________________________________________________
______________________________________________________
• Only count actual money spent. What is
______________________________________________________
the financial burden caused by drugs/alcohol? D25. How many days have you been treated in ______________________________________________________
an outpatient setting for alcohol or drugs in the
______________________________________________________
______________________________________________________
How many days in the past 30 have you experienced: ______________________________________________________
• Include: Craving, withdrawal symptoms, disturbing effects of use, or wanting to stop and being unable to. ______________________________________________________
For Questions D28+D30, ask the patient to use the Patient Rating scale.
The patient is rating the need for additional substance abuse treatment.
How troubled or bothered have you been in the past 30 days ______________________________________________________
______________________________________________________
• Include: Craving, withdrawal symptoms, disturbing effects of use, or wanting to stop and being unable to. ______________________________________________________
How important to you now is treatment for these: ______________________________________________________
______________________________________________________
How many days in the past 30 have you experienced: ______________________________________________________
• Include: Craving, withdrawal symptoms, ______________________________________________________
disturbing effects of use, or wanting to stop and being unable to. For Questions D29+D31, ask the patient to use the Patient Rating scale.
______________________________________________________
The patient is rating the need for additional substance abuse treatment.
How troubled or bothered have you been in the past 30 days by ______________________________________________________
______________________________________________________
How important to you now is treatment for these: ______________________________________________________
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 L3-16 = 00, then question L17 = "NN". • Do not include misdemeanor offenses from questions L18-20 below. ______________________________________________________
• Convictions include fines, probation, incarcerations, suspended sentences, guilty pleas, and plea bargaining. ______________________________________________________
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. ______________________________________________________
______________________________________________________
• Of 2 weeks or more. Enter "NN" if never incarcerated. Mos. ______________________________________________________
• Use code 03-16, 18-20. If multiple charges, ______________________________________________________
choose most severe. Enter "NN" if never incarcerated. ______________________________________________________
______________________________________________________
• Use the number of the type of crime committed: 03-16 ______________________________________________________
• Refers to Q. L24. If more than one, choose most severe. LEGAL STATUS (cont.)
LEGAL COMMENTS
(Include question number with your notes) _____________________________________________________
• Include being arrested and released on the same day. _____________________________________________________
_____________________________________________________
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 _____________________________________________________
_____________________________________________________
L29. How important to you now is counseling _____________________________________________________
• Patient is rating a need for referral to legal counsel _____________________________________________________
INTERVIEWER SEVERITY RATING
_____________________________________________________
L30. How would you rate the patient's need for ______________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
FAMILY HISTORY

Have any of your blood-related relatives had what you would call a significant drinking, drug use, or psychiatric problem?
Specifically, was there a problem that did or should have led to treatment?
Mother's Side Alcohol Drug Psych. Father’s Side Alcohol Drug Psych. Siblings Alcohol Drug Psych.
0 = Clearly No for any relatives in that category
X = Uncertain or don't know
1 = Clearly Yes for any relatives in that category
N = Never was a relative
•In cases where there is more than one person for a category, record the occurrence of problems for any in that group. Accept the patient's judgment on these questions. FAMILY HISTORY COMMENTS
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
FAMILY/SOCIAL STATUS
FAMILY/SOCIAL COMMENTS
(Include question number with your notes) 2-Remarried 4-Separated 6-Never Married _____________________________________________________
• Common-law marriage = 1. Specify in comments. _____________________________________________________

_____________________________________________________
• If never married, then since age 18. Yrs. Mos. _____________________________________________________
• Satisfied = generally liking the situation. _____________________________________________________
_____________________________________________________
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. _____________________________________________________
• If with parents or family, since age 18. Yrs. Mos. _____________________________________________________
• Code years and months living in arrangements from Question F4. _____________________________________________________
_____________________________________________________
Do you live with anyone who:
_____________________________________________________
_____________________________________________________
_____________________________________________________
F9. With whom do you spend most of your free time? _____________________________________________________
• 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. _____________________________________________________
F11. How many close friends do you have? _____________________________________________________
• Stress that you mean close. Exclude family
members. These are "reciprocal" relationships or mutually supportive _____________________________________________________
Would you say you have had a close reciprocal relationship
_____________________________________________________
with any of the following people:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
0 = Clearly No for all in class X = Uncertain or "I don't know 1 = Clearly Yes for any in class N = Never was a relative • By reciprocal, you mean "that you would do anything you could to help them out FAMILY/SOCIAL (cont.) CONFIDENCE RATING
Is the above information significantly distorted by:
Have you had significant periods in which you have experienced
serious problems getting along with:
0 – No, 1 - Yes
FAMILY/SOCIAL COMMENTS
(Include question number with your notes) ______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
• "Serious problems" mean those that endangered the relationship. ______________________________________________________
A "problem" requires contact of some sort, either by telephone or in person. If no ______________________________________________________
Has anyone ever abused you?
0- No 1-Yes
______________________________________________________
• Made you feel bad through harsh words. ______________________________________________________
______________________________________________________
______________________________________________________
How many days in the past 30 have you had serious conflicts:
______________________________________________________
______________________________________________________
For Questions F32-35, ask the patient to use the Patient Rating scale.
How troubled or bothered have you been in the past 30 days by:
______________________________________________________
______________________________________________________
How important to you now is treatment or counseling for these:
______________________________________________________
• Patient is rating his/her need for counseling for family ______________________________________________________
problems, not whether they 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 F32-35, ask the patient to use the Patient Rating scale.
How troubled or bothered have you been in the past 30 days by:
______________________________________________________
______________________________________________________
How important to you now is treatment or counseling for these:
______________________________________________________
• 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. INTERVIEWER SEVERITY RATING
______________________________________________________
F36. How would you rate the patient's need for family and/or social counseling? PSYCHIATRIC STATUS
How many times have you been treated for any
PSYCHIATRIC STATUS COMMENTS
(Include question number with your comments) psychological or emotional problems:
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 _____________________________________________________
• Enter diagnosis in comments if known. _____________________________________________________
_____________________________________________________
Have you had a significant period of time (that was not a direct
_____________________________________________________
result of alcohol/drug use) in which you have:
0-No 1-Yes
Past 30 Days Lifetime
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
P6. Experienced hallucinations-saw things/ _____________________________________________________
heard voices that others didn’t see/hear? _____________________________________________________
_____________________________________________________
Have you had a significant period of time ( despite your alcohol
_____________________________________________________
and drug use) in which you have:
0-No 1-Yes
Past 30 Days Lifetime
_____________________________________________________
_____________________________________________________
• Patient can be under the influence of alcohol / drugs. _____________________________________________________
P9. Experienced serious thoughts of suicide? • Patient seriously considered a plan for taking _____________________________________________________
his/her life. Patient can be under the influence _____________________________________________________
• Include actual suicidal gestures or attempts. _____________________________________________________
• Patient can be under the influence of _____________________________________________________
_____________________________________________________
• Prescribed for the patient by a physician. Record "Yes" if a medication _____________________________________________________
was prescribed even if the patient is not taking it. _____________________________________________________
_____________________________________________________
• This refers to problems noted in Questions P4-P10. _____________________________________________________
For Questions P13-P14, ask the patient to use the Patient Rating scale
_____________________________________________________
_____________________________________________________
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? PSYCHIATRIC STATUS (cont.)
The following items are to be completed by the interviewer:
PSYCHIATRIC STATUS COMMENTS
At the time of the interview, the patient was:
0-No 1-Yes
(Include question number with your notes) ______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
P18. Having trouble with reality testing, thought ______________________________________________________
______________________________________________________
______________________________________________________

______________________________________________________
______________________________________________________
INTERVIEWER SEVERITY RATING
P21 . How would you rate the patient's need ______________________________________________________
for psychiatric/psychological treatment? ______________________________________________________
CONFIDENCE RATING
Is the above information significantly distorted by:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
G12. Special Code
______________________________________________________
3. Patient unable to respond ( language or intellectual barrier, under ______________________________________________________
______________________________________________________

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

Source: http://www.tresearch.org/wp-content/uploads/2012/09/ASI_Clinical_Training.pdf