Protocol - Addiction Severity Index

INSTRUCTIONS

1. Leave No Blanks-Where appropriate, code items:

X = question not answered

N = question not applicable

Use only one character per item.

2. Questions that are italicized are to be asked at follow-up. Items with an asterisk are cumulative and should be rephrased at follow-up (see Manual).

3. Space is provided after sections for additional comments.

SEVERITY RATINGS

The severity ratings are interviewer estimates of the patient’s need for additional treatment in each area. The scales range from 0 (no treatment necessary) to 9 (treatment needed to intervene in life-threatening situation). Each rating is based upon the patient’s history of problems, symptoms, present condition, and subjective assessment of his treatment needs in a given area. For a detailed description of severity ratings’ derivation procedures and conventions, see manual. Note: These severity ratings are optional.

SUMMARY OF PATIENT’S RATING SCALE

0-Not at all

1-Slightly

2-Moderately

3-Considerably

4-Extremely

1. RELIGIOUS PREFERENCE

1[ ]Protestant

2[ ]Catholic

3[ ]Jewish

4[ ]Islamic

5[ ]Other

6[ ]None

2. Have you been in a controlled environment in the past 30 days?

1[ ]No - Go to Q4

2[ ]Jail

3[ ]Alcohol or Drug Treatment

4[ ]Medical Treatment

5[ ]Psychiatric Treatment

6[ ]Other ___________________________

3. How many days? |__|__|

Medical Status

4. *How many times in your life have you been hospitalized for medical problems? (Include o.d.’s, d.t.’s, exclude detox.)

5. How long ago was your last hospitalization for a physical problem

|__|__| |__|__|

YRS MOS

6. Do you have any chronic medical problems which continue to interfere with your life?

0[ ]No

1[ ]Yes _____________ Specify

7. Are you taking any prescribed medication on a regular basis for a physical problem?

0[ ]No

1[ ]Yes

8. Do you receive a pension for a physical disability? (Exclude psychiatric disability.)

0[ ]No

1[ ]Yes _____________ Specify

9. How many days have you experienced medical problems in the past 30?

|__|__|

FOR QUESTIONS 10 and 11 PLEASE ASK PATIENT TO USE THE PATIENT RATING SCALE

10. How troubled or bothered have you been by these medical problems in the past 30 days? |__|

11. How important to you now is treatment for these medical problems? |__|

INTERVIEWER SEVERITY RATING

How would you rate the patient’s need for medical treatment?

CONFIDENCE RATINGS

Is the above information significantly distorted by:

13. Patient’s misrepresentation?

0[ ]No

1[ ]Yes

14. Patient’s inability to understand?

0[ ]No

1[ ]Yes

EMPLOYMENT/SUPPORT STATUS

15. Do you have a profession, trade, or skill?

0[ ]No

1[ ]Yes _____________ Specify

16. Do you have a valid driver’s license?

0[ ]No

1[ ]Yes

17. Do you have an automobile available for use? (Answer No if no valid driver’s license.)

0[ ]No

1[ ]Yes

How long was your longest full-time job?

|__|__| |__|__|

YRS MOS

19. *Usual (or last) occupation.

_________________ (Specify in detail)

20. Does someone contribute to your support in any way?

0[ ]No

1[ ]Yes

21. (ONLY IF ITEM 20 IS YES) Does this constitute the majority of your support?

0[ ]No

1[ ]Yes

22. Usual employment pattern, past 3 years.

1[ ]full time (40 hrs/wk)

2[ ]part time (reg. hrs)

3[ ]part time (irreg, daywork)

4[ ]student

5[ ]service

6[ ]retired/disability

7[ ]unemployed

8[ ]in controlled environment

23. How many days were you paid for working in the past 30? (include "under the table" work"

24. How much money did you receive from the following sources in the past 30 days?

Employment (net income) |__|__|__|__|

Unemployment compensation |__|__|__|__|

DPA |__|__|__|__|

Pension, benefits or Social Security |__|__|__|__|

Mate, family or friends (Money for personal expenses.) |__|__|__|__|

Illegal |__|__|__|__|

25. How many people depend on you for the majority of their food, shelter, etc.? [ ]

26. How many days have you experienced employment problems in the past 30? [ ]

FOR QUESTIONS 27 & 28 PLEASE ASK PATIENT TO USE THE PATIENT’S RATING SCALE

27. How troubled or bothered have you been by these employment problems in the past 30 days?

28. How important to you now is counseling for these employment problems?

INTERVIEWER SEVERITY RATING

29. How would you rate the patient’s need for employment counseling?

CONFIDENCE RATINGS

Is the above information significantly distorted by:

30. Patient’s misrepresentation?

0[ ]No

1[ ]Yes

31. Patient’s inability to understand?

0[ ]No

1[ ]Yes

DRUG/ALCOHOL USE

	PAST 30 Days	LIFETIME Yrs.	USE Rt of adm.
32. Alcohol - Any use at all	|__|__|	|__|__|	|__|
33. Alcohol - To intoxication	|__|__|	|__|__|	|__|
34. Heroin	|__|__|	|__|__|	|__|
35. Methadone	|__|__|	|__|__|	|__|
36. Other opiates/analgesics	|__|__|	|__|__|	|__|
37. Barbiturates	|__|__|	|__|__|	|__|
38. Other sed/hyp/tranq.	|__|__|	|__|__|	|__|
39. Cocaine	|__|__|	|__|__|	|__|
40. Amphetamines	|__|__|	|__|__|	|__|
41. Cannabis	|__|__|	|__|__|	|__|
42. Hallucinogens	|__|__|	|__|__|	|__|
43. Inhalants	|__|__|	|__|__|	|__|

44. More than one substance per day (Include alcohol)/ |__|__| |__|__|

Note: See manual for representative examples for each drug class

*Route of Administration: 1 = Oral, 2 = Nasal, 3 = Smoking, 4 = Non IV injection, 5 = IV injection

45. Which substance is the major problem? Please code as above or 00-No problem; 15-Alcohol & Drug (Dual addiction); 16-Polydrug; when not clear, ask patient.

|__|__|

46. How long was your last period of voluntary abstinence from this major substance? (00-never abstinent)

|__|__|

47. How many months ago did this abstinence end?

How many times have you:

48. *Had alcohol d.t.’s |__|__|

49. *Overdosed on drugs |__|__|

How many times in your life have you been treated for:

50. *Alcohol Abuse: |__|__|

51. *Drug Abuse: |__|__|

How many of these were detox only?

52. *Alcohol |__|__|

53. *Drug |__|__|

How much would you say you spent during the past 30 days on:

54. Alcohol |__|__||__|__|

55. Drug |__|__||__|__||

56. How many days have you been treated in an outpatient setting for alcohol or drugs in the past 30 days (Include NA, AA). |__|__|

How many days in the past 30 have you experienced:

57. Alcohol Problems |__|__|

58. Drug Problems |__|__|

FOR QUESTIONS 59 & 60 PLEASE ASK PATIENT TO USE THE PATIENT’S RATING SCALE

How troubled or bothered have you been in the past 30 days by these:

59. Alcohol Problems |__|

60. Drug Problems |__|

How important to you now is treatment for these:

61. Alcohol Problems |__|

62. Drug Problems |__|

INTERVIEWER SEVERITY RATING

How would you rate the patient’s need for treatment for:

63. Alcohol Abuse |__|

64. Drug Abuse |__|

CONFIDENCE RATINGS

Is the above information significantly distorted by:

65. Patient’s misrepresentation?

0[ ]No

1[ ]Yes

66. Patient’s inability to understand?

0[ ]No

1[ ]Yes

LEGAL STATUS

67. Was this admission prompted or suggested by the criminal justice system (judge, probation/parole officer, etc.)

0[ ]No

1[ ]Yes

68. Are you on probation or parole?

0[ ]No

1[ ]Yes

How many times in your life have you been arrested and charged with the following:

69. *Shoplifting/vandalism |__|__|

70. *Parole/probation violations |__|__|

71. *Drug charges |__|__|

72. *Forgery |__|__|

73. *Weapons offense |__|__|

74. *Burglary, larceny, B&E |__|__|

75. *Robbery |__|__|

76. *Assault |__|__|

77. *Arson |__|__|

78. *Rape |__|__|

79. *Homicide, manslaughter |__|__|

80. *Prostitution |__|__|

81. *Contempt of court |__|__|

82. *Other |__|__|

83. *How many of these charges resulted in convictions? |__|__|

How many times in your life have you been charged with the following:

84. *Disorderly conduct, vagrancy, public intoxication |__|__|

85. *Driving while intoxicated |__|__|

86. *Major driving violations (reckless driving, speeding, no license, etc.) |__|__|

87. *How many months were you incarcerated in your life?

|__|__|

MOS.

88. How long was your last incarceration?

|__|__|

MOS.

89. What was it for? (Use code 3-16, 18-20. If multiple charges, code most severe)

|__|__|

90. Are you presently awaiting charges, trial or sentence?

0[ ]No

1[ ]Yes

91. What for (if multiple charges, use most severe). |__|__|

92. How many days in the past 30 were you detained or incarcerated? |__|__|

93. How many days in the past 30 have you engaged in illegal activities for profit? |__|__|

FOR QUESTION 94 & 95 PLEASE ASK PATIENT TO USE THE PATIENT’S RATING SCALE

94. How serious do you feel your present legal problems are? (Exclude civil problems)

|__|

95. How important to you now is counseling or referral for these legal problems? |__|

INTERVIEWER SEVERITY RATING

96. How would you rate the patient’s need for legal services or counseling? |__|

CONFIDENCE RATINGS

Is the above information significantly distorted by:

97. Patient’s misrepresentation?

0[ ]No

1[ ]Yes

98. Patient’s inability to understand?

0[ ]No

1[ ]Yes

FAMILY/SOCIAL RELATIONSHIPS

99. Marital Status |__|

1-Married

2-Remarried

3-Widowed

4-Separated

5-Divorced

6-Never Married

100. How long have you been in this marital status? (If never married, since age 18).

|__|__| |__|__|

YRS MOS

101. Are you satisfied with this situation?

0[ ]No

1[ ]Indifferent

2[ ]Yes

102. *Usual living arrangements (past 3 yr.) |__|

1-With sexual partner and children

2-With sexual partner alone

3-With children alone

4-With parents

5-With family

6-With friends

7-Alone

8-Controlled environment

9-No stable arrangements

103. How long have you lived in these arrangements. (If with parents or family, since age 18).

|__|__| |__|__|

YRS MOS

104. Are you satisfied with these living arrangements?

0[ ]No

1[ ]Indifferent

2[ ]Yes

Do you live with anyone who: 0 = No, 1 = Yes

105. Has a current alcohol problem? [ ]

Uses non-prescribed drugs? [ ]

107. With whom do you spend most of your free time: [ ]

1-Family

2-Friends

3-Alone

108. Are you satisfied with spending your free time this way?

0[ ]No

1[ ]Indifferent

2[ ]Yes

109. How many close friends do you have? |__|

Direction for 110-124: Place "0" in relative category where the answer is clearly no for all relatives in the category; "1" where the answer is clearly yes for any relative within the category; "X" where the answer is uncertain or "I don’t know" and "N" where there never was a relative from that category.

Would you say you have had close, long lasting, personal relationships with any of the following people in your life:

110. Mother [ ]

Father [ ]

Brothers/Sisters [ ]

Sexual Partner/Spouse [ ]

Children [ ]

Friends [ ]

Have you had significant periods in which you have experienced serious problems getting along with:

0 = No

1 = Yes

	PAST 30 DAYS	IN YOUR LIFE
116. Mother	[ ]	[ ]
117. Father	[ ]	[ ]
118. Brothers/Sisters	[ ]	[ ]
119. Sexual partner/spouse	[ ]	[ ]
120. Children	[ ]	[ ]
121. Other significant family __________	[ ]	[ ]
122. Close friends	[ ]	[ ]
123. Neighbors	[ ]	[ ]
124. Co-Workers	[ ]	[ ]

Did any of these people (Questions 116-124) abuse you:

0 = No, 1 = Yes

	PAST 30 DAYS	IN YOUR LIFE
125. Emotionally (make you feel bad through harsh words)?	[ ]	[ ]
126. Physically (cause you physical harm)?	[ ]	[ ]
127. Sexually (force sexual advances or sexual acts)?	[ ]	[ ]

How many days in the past 30 have you had serious conflicts:

128. With your family? |__|__|

129. With other people? (excluding family) |__|__|

FOR QUESTIONS 130-133 PLEASE ASK PATIENT TO USE THE PATIENT’S RATING SCALE

How troubled or bothered have you been in the past 30 days by these:

130. Family problems |__|

131. Social problems |__|

How important to you now is treatment or counseling for these:

132. Family problems |__|

133. Social problems |__|

INTERVIEWER SEVERITY RATING

134. How would you rate the patient’s need for family and/or social counseling?

|__|

CONFIDENCE RATINGS

Is the above information significantly distorted by:

135. Patient’s misrepresentation?

0[ ]No

1[ ]Yes

136. Patient’s inability to understand?

0[ ]No

1[ ]Yes

PSYCHIATRIC STATUS

How many times have you been treated for any psychological or emotional problems?

137. *In a hospital |__|__|

138. *As an Opt, or Priv, patient |__|__|

139. Do you receive a pension for a psychiatric disability? 0 = No, 1 = Yes [ ]

Have you had a significant period (that was not a direct result of drug/alcohol use), in which you have: 0 = No, 1 = Yes

	PAST 30 DAYS	IN YOUR LIFE
140. Experienced serious depression	[ ]	[ ]
141. Experienced serious anxiety or tension	[ ]	[ ]
142. Experienced hallucinations	[ ]	[ ]
143. Experienced trouble understanding, concentrating, or remembering	[ ]	[ ]
144. Experienced trouble controlling violent behavior	[ ]	[ ]
145. Experienced serious thoughts of suicide	[ ]	[ ]
146. Attempted suicide	[ ]	[ ]
147. Been prescribed medication for any psychological emotional problem	[ ]	[ ]

148. How many days in the past 30 have you experienced these psychological or emotional problems? |__|__|

FOR QUESTIONS 149 & 150 PLEASE ASK PATIENT TO USE THE PATIENTS RATING SCALE

149. How much have you been troubled or bothered by these psychological or emotional problems in the past 30 days? |__|

150. How important to you now is treatment for these psychological problems? |__|

THE FOLLOWING ITEMS ARE TO BE COMPLETED BY THE INTERVIEWER

At the time of the interview, is patient: 0 = No, 1 = Yes

151. Obviously depressed/withdrawn [ ]

152. Obviously hostile [ ]

153. Obviously anxious/nervous [ ]

154. Having trouble with reality testing thought disorders, paranoid thinking [ ]

155. Having trouble comprehending, concentrating, remembering [ ]

156. Having suicidal thoughts [ ]

INTERVIEWER SEVERITY RATING

157. How would you rate the patient’s need for psychiatric/psychological treatment? |__|

CONFIDENCE RATINGS

Is the above information significantly distorted by:

158. Patient’s misrepresentation?

0[ ]No

1[ ]Yes

159. Patient’s inability to understand?

0[ ]No

1[ ]Yes