6.3 Brief Screening Instruments

6.3 Brief Screening Instruments

Quick Answer: Brief screens sort risk. They do not diagnose a DSM-5-TR substance use disorder. The 10-item AUDIT is scored 0–40; a total of 8 or higher is the conventional World Health Organization (WHO) positive screen. Know AUDIT-C, CAGE, DAST, and ASSIST by what they cover, how they score, and what a cutoff does not prove.

Domain II.B of the ADC exam asks counselors to use established screening and assessment methods. Brief instruments belong at the front of that workflow: they are short, scored, and designed to flag who needs a fuller interview. Comprehensive tools such as the Addiction Severity Index (ASI) are the next section. Diagnostic criteria are a later Domain II chapter. Mixing those three jobs is the most common exam error.

Screening versus diagnosis

Screening answers: Is there enough concern to look further? Diagnosis answers: Does this person meet DSM-5-TR criteria for a substance use disorder, and at what severity? A high screen can occur in someone who does not meet diagnostic criteria. A low screen can miss a person who is minimizing, cognitively impaired, or asked the wrong tool (for example, an alcohol-only screen in a person whose only problem is methamphetamine).

Document the instrument name, version, score, cutoff you used, and next step. Do not write "client is an alcoholic per CAGE."

AUDIT: 10 items, score 0–40, conventional positive screen 8+

The Alcohol Use Disorders Identification Test (AUDIT) was developed by WHO for primary-care screening. It has 10 items. Most items are scored 0–4. Items 9 and 10 (injury; others concerned) are scored 0, 2, or 4. The total ranges from 0 to 40.

Content clusters (useful for interpretation, not separate official diagnoses):

• Items 1–3: consumption (frequency, typical quantity, binge frequency).
• Items 4–6: dependence-related signs (impaired control, morning use, failed expectations).
• Items 7–10: harmful consequences (guilt, blackouts, injury, others' concern).

WHO's conventional positive screen is a total of 8 or higher, indicating hazardous or harmful alcohol use that warrants at least brief advice and further assessment. Many manuals then band scores roughly as 0–7 low risk, 8–15 hazardous (brief advice), 16–19 harmful (brief intervention plus monitoring), and 20–40 possible dependence needing specialist assessment. Those bands guide next clinical action. They still are not a DSM-5-TR diagnosis.

Some settings lower the cutoff (for example, 7 or lower) for women, older adults, or hepatic disease. If an exam item says conventional or WHO, use 8+ unless the stem names a different rule.

Worked AUDIT total

A client drinks 2–3 times per week (item 1 = 3), typically 5–6 drinks (item 2 = 2), and weekly has six or more on one occasion (item 3 = 3). Impaired control is monthly (item 4 = 2). Failed expectations, morning drinking, and blackouts are never (0). Guilt is monthly (item 7 = 2). No injury (item 9 = 0). A clinician suggested cutting down in the past year (item 10 = 4). Total = 16. That is a positive screen in the harmful band. The counselor's next job is a fuller alcohol history and medical risk review — not writing "severe AUD" in the diagnosis line from this number alone.

AUDIT-C

AUDIT-C is the first three AUDIT consumption items. Each is 0–4, so the total is 0–12. Zero usually means no drinking in the past year on that tool.

A widely used U.S. primary-care convention (Bradley and colleagues; often cited in NIAAA-linked materials) treats 4 or more as positive for men and 3 or more as positive for women. Other systems (including some VA clinical reminders) use a different number, such as 5 for both sexes. On the exam, if the stem does not name a system, know the 3-item / 0–12 structure and that cutoffs are convention-specific. A positive AUDIT-C still is not dependence.

A practical caveat used in several clinical guides: if all AUDIT-C points come from item 1 (frequency) and typical quantity is low, the person may still be under recommended limits — review the drinking pattern rather than treating the number as destiny.

CAGE

CAGE (Ewing) is four yes/no questions. The acronym is the item list:

1. Cut down — Have you felt you should cut down?
2. Annoyed — Have people annoyed you by criticizing your drinking?
3. Guilty — Have you felt guilty about drinking?
4. Eye-opener — Have you had a drink first thing in the morning to steady nerves or get rid of a hangover?

Each yes = 1. Total 0–4. A score of 2 or more is a conventional clinically significant positive screen. CAGE does not ask quantity or frequency, so a person can drink hazardously and still score 0, and a person in long-term recovery can still score 2+ on lifetime "ever" wording. CAGE-AID adapts the same four ideas to alcohol or drugs. CAGE is fast; it is a poor standalone severity measure.

DAST

The Drug Abuse Screening Test (DAST) (Skinner) screens drug-related problems. It does not score alcohol. That single fact kills many mixed-up answers.

The DAST-10 is the brief version most used at intake. Nine items score 1 for yes; item 3 ("Are you always able to stop using drugs when you want to?") scores 1 for no. Total 0–10. Common interpretation bands:

A score of 3 or more is a widely used case-finding cutoff for further assessment. DAST-20 exists (case-finding often cited at 6+). Name the version you used. DAST still is not a DSM diagnosis and does not identify which drug class is driving the score — that takes a substance-by-substance history (or ASSIST).

ASSIST

The WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (commonly v3.1) is an interviewer-administered screen across substance classes: tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, opioids, and other. It produces a Specific Substance Involvement (SI) score per class, not one grand total that replaces all others.

Typical risk bands on WHO scoring sheets:

Injection drug use is flagged separately and is a clinical priority even when an SI score is not in the high band. ASSIST is stronger than CAGE when you need a multi-drug map. It still does not assign DSM-5-TR diagnoses.

Choosing a brief screen on the exam

Do not combine scores across tools (AUDIT 8 + DAST 3 does not equal a "combined diagnosis of 11"). Do not skip safety questions because a screen was negative. Do not tell a client "you have alcoholism" because CAGE was 2.

Worked choice

A primary-care referral says "possible alcohol problem, unknown drugs." A reasonable first pair is AUDIT (or AUDIT-C if time is extremely short) plus DAST-10 or ASSIST. AUDIT alone will miss a fentanyl problem. DAST alone will miss hazardous beer intake. ASSIST can cover both but takes more interview time. The exam's best answer is the tool that matches the question the counselor needs answered, not the longest acronym.