CSAT’s
Knowledge Application Program
KAP Keys for Clinicians
Based on TIP 11
Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov
Introduction
Key 1 Simple Screening Instrument for Substance Abuse
Key 2 Simple Screening Instrument for Infectious Diseases
Ordering Information
These KAP Keys were developed to accompany the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT). These KAP Keys are based entirely on TIP 11 and are designed to meet the needs of the busy clinician for concise, easily accessed “how-to” information.
For more information on the topics in these KAP Keys, see TIP 11.
Other Treatment Improvement Protocols that are relevant to these KAP Keys:
TIP 6, Screening for Infectious Diseases Among Substance Abusers (1993, Reprinted 1995) BKD131
TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (1993) BKD138
TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (1994, Reprinted 1999) BKD134
TIP 16, Alcohol and Other Drug Screening of Hospitalized Trauma Patients (1995) BKD164
TIP 31, Screening and Assessing Adolescents for Substance Use Disorder (1999) BKD306
Key 1 Simple Screening Instrument for Substance Abuse
(Administered by Interviewer)
Short version: Boldface questions only.
Long version: All questions.
Introductory Statement Made by Interviewer
I’m going to ask you a few questions about your use of alcohol and drugs during the last 6 months. Your answers will be kept private. Based on your answers to these questions, I may advise you to get a more complete assessment. This would be voluntary.
During the last 6 months
1. Have you used alcohol (such as wine, beer, or hard liquor) or drugs (such as pot, coke, heroin or other opioids, uppers, downers, hallucinogens, or inhalants)? Yes No If no, stop or skip to question 14.
2. Have you felt that you use too much alcohol or too many drugs? Yes No
3. Have you tried to cut down on or quit drinking or using drugs? Yes No
4. Have you gone to anyone (such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program) for help because of your drinking or drug use? Yes No
5. Have you had any of the following:
Blackouts or other periods of memory loss?
Injury to your head after drinking or using drugs?
Convulsions or delirium tremens (DTs)?
Hepatitis or other liver problems?
Feelings of being sick, shaky, or depressed when you stopped drinking or using drugs?
Feelings of “coke bugs,” or a crawling feeling under the skin, after you stopped using drugs?
Injury after drinking or using drugs?
The desire to use needles to shoot drugs?
6. Has drinking or drug use caused problems between you and your family or friends? Yes No
7. Has your drinking or drug use caused problems at school or work? Yes No
8. Have you been arrested or had other legal problems (such as being charged with bouncing checks, driving while intoxicated, theft, or drug possession)? Yes No
9. Have you lost your temper or gotten into arguments or fights while drinking or using drugs? Yes No
10. Do you need to drink or use drugs more and more to get the effect you want? Yes No
11. Do you spend a lot of time thinking about or trying to get alcohol or drugs? Yes No
12. When drinking or using drugs, are you more likely to do something you wouldn’t normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone? Yes No
13. Do you feel bad or guilty about your drinking or drug use? Yes No
Now I have some questions that are not limited to the last 6 months.
14. Have you ever had a drinking or drug problem? Yes No
15. Have any of your family members ever had a drinking or drug problem? Yes No
16. Do you feel that you have a drinking or drug problem now? Yes No
Thank you for answering these questions. Do you have any questions for me? Is there something I can do to help you?
Observation Checklist
The following signs and symptoms may indicate a substance abuse problem in the individual being screened:
Scoring
For short version (boldface questions), any yes answers by the respondent merit followup questioning.
Items 1 and 15 are not scored. For the remaining questions, score 1 for yes and 0 for no.
__2 __3 __4 __5 __6 __7 __8 __9 __10 __11 __12 __13 __14 __16 ____Total score
Preliminary Interpretation of Results
0 or 1: Degree of risk for alcohol and drug abuse is none to low
2 or 3: Degree of risk for alcohol and drug abuse is minimal
≥ 4: Degree of risk for alcohol and drug abuse is moderate to high; possible need for further assessment
See TIP 11, pages 12 and 13.
Key 2 Simple Screening Instrument for Infectious Diseases
(Administered by Interviewer)
Introductory Statement Made by Interviewer
I’m going to ask you a few questions about your health and lifestyle. I want you to know that my agency will not give this information to anyone without your permission. Based on your answers I may advise you to get a physical exam or further tests. This would be voluntary—it would be your choice whether to have the exam. If you do get an exam and are found to have certain diseases, they must be reported to the health department.
1. Have you seen a doctor or other healthcare provider in the last 3 months? (A; see Key) Yes No
2. a. Do you live on the street or in a shelter? (C, F) Yes No
b. Have you ever been in jail? (C, F) Yes No
3. Have you ever been told you tested positive for HIV (the virus that causes AIDS)? (G) Yes No
4. Women: Have you missed your last two periods? (D, E, F) Yes No
5 Have you ever had a positive TB skin test? I mean a test where you got a shot in your forearm and a few days later a hard bump like a blister appeared. (C) Yes No
6. Have you ever been told you have TB? Has anybody you know or have lived with been diagnosed with TB in the last year? (C) Yes No
7. a. Within the last 30 days, have you had any of the following symptoms lasting for more than 2 weeks? (B, C, F)
Fever
Drenching night sweats that were so bad you had to change your clothes or the sheets on the bed
Attacks of coughing up blood
Shortness of breath
Lumps or swollen glands in the neck or armpits
Weight loss without trying
Diarrhea (“runs”) lasting more than a week.
b. Do you live with someone who has any of the following symptoms? (C)
Attacks of coughing up blood
Drenching night sweats.
8. Do you use needles to shoot drugs? (F) Yes No
9. Do you use coke or crack? (D, F) Yes No
10. In the last 6 months, have you had VD (venereal diseases) or an STD (sexually transmitted disease) like syphilis, the clap (gonorrhea), chlamydia, NGU (non-gonococcal urethritis), or trichomoniasis (trich)? (D, F) Yes No
11. Have you, or anyone you’ve had sex with, had any of the following symptoms within the last 30 days: (D, F)
Sore or ulcer on the penis/vagina (“down there”)?
Rash, spots, or other skin problems, especially on your palms or the soles of your feet?
Women: A vaginal discharge that is different from what you usually have?
Women: Pain when you have vaginal sex?
Men: Discharge from the penis?
12. Have you had sex with more than two people—at different times—in the last 6 months? I mean any type of vaginal, rectal, or oral contact, such as you “went down” on your partner or he or she “went down” on you, with or without a condom? (D, F) Yes No
13. Have you used your rectum for sex? (Use regionally appropriate terminology to indicate anal penetration, as opposed to other types of sexual contact.) (F) Yes No
14. In the last 6 months, have you had sex with someone in return for anything like money, alcohol or drugs, a place to stay, or just to survive? (D, F) Yes No
15. Have you ever been forced to have sex against your will? (A) Yes No
Key
A = Needs supporting data
B = General medical evaluation
C = TB screening
D = STD assessment
E = Prenatal care
F = HIV/AIDS counseling, testing, referral, and partner notification (Assessment for hepatitis B and hepatitis C is also warranted.)
G = HIV/AIDS care/early intervention
See TIP 11, pages 23–26.
TIP 11
Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases
Easy Ways to Obtain FREE Copies of All TIP Products
1.Call SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at 800–729–6686, TDD (hearing impaired) 800–487–4889
2.Visit CSAT’s Web site at www.csat.samhsa.gov
Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
DHHS Publication No. (SMA) 01-3560
Printed 2001