2.2 Standardized Screening Tools: AUDIT, DAST-10, CAGE, CRAFFT & ASSIST
Key Takeaways
- AUDIT (Alcohol Use Disorders Identification Test) is a 10-item WHO tool; total scores range 0–40 (0–7 low risk, 8–15 moderate risk requiring brief intervention, 16–19 high risk requiring counseling/monitoring, 20–40 severe risk requiring specialist referral).
- CAGE is a concise 4-item screening mnemonic (Cut down, Annoyed, Guilty, Eye-opener); a score of ≥2 is clinically significant and indicates high risk for alcohol dependency.
- DAST-10 measures non-alcohol drug misuse over the past 12 months; score 0 = no problem, 1–2 = low risk, 3–5 = moderate risk, 6–8 = substantial risk, 9–10 = severe risk.
- CRAFFT is specifically validated for adolescents (<21 years); Part B evaluates a 6-item mnemonic (Car, Relax, Alone, Forget, Friends, Trouble), with a score ≥2 indicating high risk for substance-related harm.
- WHO ASSIST calculates a Specific Substance Involvement (SSI) score ranging from 0–3 (low risk), 4–26 (moderate risk requiring brief intervention), to ≥27 (high risk requiring intensive specialist treatment).
Standardized Screening Tools: AUDIT, DAST-10, CAGE, CRAFFT & ASSIST
Universal Screening in Addictions Nursing
Universal screening for substance misuse is a foundational component of evidence-based nursing assessment. Early identification of unhealthy alcohol and drug use prevents disease progression, reduces trauma and injury rates, and improves overall medical outcomes. Screening differs fundamentally from diagnostic assessment: while diagnostic evaluation (such as DSM-5-TR scoring) establishes the formal presence of a disorder, screening rapidly categorizes individuals along a risk continuum to guide immediate clinical intervention.
The American Society of Addiction Medicine (ASAM) and the Substance Abuse and Mental Health Services Administration (SAMHSA) advocate for the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model across all healthcare settings, including primary care, emergency departments, trauma centers, and inpatient units.
Alcohol Use Disorders Identification Test (AUDIT & AUDIT-C)
Developed by the World Health Organization (WHO), the Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening instrument designed to detect hazardous and harmful alcohol consumption as well as alcohol dependence.
AUDIT Structure & Item Domains
- Items 1–3 (Consumption Domain): Assess frequency of drinking, typical quantity consumed, and frequency of heavy episodic drinking (binge drinking: ≥5 drinks for men, ≥4 drinks for women).
- Items 4–6 (Dependence Symptoms): Assess impaired control over drinking, increased salience of drinking, and morning drinking.
- Items 7–10 (Alcohol-Related Consequences): Assess guilt, blackout/amnesia, alcohol-related injuries, and concerns expressed by relatives or health professionals.
Each item is scored from 0 to 4, yielding a total score between 0 and 40.
AUDIT Risk Stratification & Clinical Intervention Matrix
| Zone | Total AUDIT Score | Risk Level | Recommended Clinical Intervention (SBIRT) |
|---|---|---|---|
| Zone I | 0 – 7 | Low Risk / Abstinent | Alcohol education and primary prevention messages. |
| Zone II | 8 – 15 | Moderate Risk (Hazardous) | Brief Intervention (BI): Motivational advice to reduce drinking limits. |
| Zone III | 16 – 19 | High Risk (Harmful) | Brief Counseling & Monitoring: Repeated BI plus specialized outpatient monitoring. |
| Zone IV | 20 – 40 | Severe Risk (Possible Dependence) | Referral to Treatment (RT): Diagnostic evaluation and specialist addiction treatment. |
The AUDIT-C Abbreviated Screen
The AUDIT-C consists exclusively of the first 3 consumption questions. Total scores range from 0 to 12. Cut-off scores indicating a positive screen are ≥4 for adult men and ≥3 for adult women and older adults. A positive AUDIT-C prompts administration of the full 10-item AUDIT.
Drug Abuse Screening Test (DAST-10)
The Drug Abuse Screening Test (DAST-10) is a 10-item self-report scale designed to screen for non-alcohol drug misuse over the preceding 12 months. Items are answered with a binary "Yes" (1 point) or "No" (0 points).
DAST-10 Clinical Scoring Breakdown
- Score 0: No problem reported. Action: Encouragement and standard health monitoring.
- Score 1 – 2: Low level of risk. Action: Brief intervention focused on harm reduction.
- Score 3 – 5: Moderate (Intermediate) level of risk. Action: Intensive brief intervention and further diagnostic evaluation.
- Score 6 – 8: Substantial level of risk. Action: Formal assessment, referral to specialized addiction treatment program.
- Score 9 – 10: Severe level of risk. Action: Immediate referral to specialized addiction treatment specialist or inpatient medical detox.
CAGE Questionnaire: Utility & Limitations
The CAGE questionnaire is one of the most widely recognized brief alcohol screening tools in clinical medicine. It consists of four direct questions represented by the CAGE mnemonic:
- C – Cut down: Have you ever felt you needed to Cut down on your drinking?
- A – Annoyed: Have people Annoyed you by criticizing your drinking?
- G – Guilty: Have you ever felt bad or Guilty about your drinking?
- E – Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
Scoring & Interpretation
Each "Yes" response receives 1 point (total score 0 to 4).
- Score of 0 – 1: Low suspicion for alcohol dependence.
- Score of ≥2: Clinically significant positive screen. Indicates high risk of alcohol dependency and requires thorough diagnostic workup.
CARN Clinical Note: CAGE is highly sensitive for lifetime alcohol dependence but lacks sensitivity for detecting early hazardous drinking patterns. Furthermore, CAGE does not establish a timeframe (e.g., past 12 months), meaning historical drinking may yield a false-positive screen in long-term recovery. For current drinking risk, AUDIT is superior.
CRAFFT Screening for Adolescent Populations
The CRAFFT screening tool is explicitly validated for children, adolescents, and young adults aged 12 to 21 years. CRAFFT integrates screening for both alcohol and illicit/prescription drugs.
CRAFFT Structure
- Part A: Asks about frequency of use in the past 12 months (alcohol, cannabis, other substances).
- Part B (The CRAFFT Mnemonic): If the adolescent reports any use in Part A, the nurse administers the 6 Part B items:
| Letter | Item Question |
|---|---|
| C | Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs? |
| R | Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? |
| A | Do you ever use alcohol or drugs while you are by yourself, Alone? |
| F | Do you ever Forget things you did while using alcohol or drugs? |
| F | Do your Family or Friends ever tell you that you should cut down on your drinking or drug use? |
| T | Have you ever gotten into Trouble while you were using alcohol or drugs? |
Scoring Thresholds
A score of ≥2 on Part B indicates a positive screen, signaling high risk for a substance use disorder or hazardous substance involvement, requiring brief motivational counseling and developmental specialist referral.
WHO ASSIST: Multi-Substance Screening
The Alcohol, Smoking and Substance Involvement Screening Test (WHO ASSIST) is an 8-item interviewer-administered tool designed to evaluate ten substance categories: tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, opioids, and other drugs.
ASSIST yields a Specific Substance Involvement (SSI) score for each substance:
- 0 – 3 (Alcohol 0 – 10): Low risk. Standard health advice.
- 4 – 26 (Alcohol 11 – 26): Moderate risk. Brief intervention and educational materials.
- 27+ (Alcohol 27+): High risk. Referral to specialist treatment.
A CARN nurse in an outpatient primary care clinic administers the 10-item AUDIT screening tool to a 35-year-old male patient. The patient receives a total score of 18. Based on standardized WHO AUDIT scoring cut-offs and SBIRT protocols, what is the most appropriate nursing intervention?
During an intake assessment, a nurse scores a patient on the CAGE questionnaire. The patient answers 'Yes' to criticized drinking (Annoyed) and morning drinking to steady nerves (Eye-opener), giving a total score of 2. What is the clinical significance of this result?
A 16-year-old high school student is screened in a pediatric clinic using the CRAFFT tool. The adolescent scores 3 on Part B (endorsing riding in a Car with an impaired driver, using substance Alone, and getting into Trouble). What action should the CARN nurse take based on CRAFFT protocols?