2.2 Screening Instruments

Why Memorize the Numbers?

IC&RC ADC items routinely give you a vignette — a 16-year-old presents to her pediatrician, or a 45-year-old man scores 9 on the AUDIT — and ask which tool to use or what the score means. You need the name, item count, target substance, cutoff, and population for each common instrument, because distractors are built by swapping one number or one population. Validated screeners are emphasized over clinical hunch for a reason: structured tools have known sensitivity and specificity, while unstructured impression misses a large share of risky use.

AUDIT (Alcohol Use Disorders Identification Test)

• Items: 10 questions (3 on consumption, 3 on dependence symptoms, 4 on alcohol-related problems).
• Substance: Alcohol only.
• Population: Adults; developed and validated cross-culturally by the World Health Organization (WHO).
• Scoring (0-40):
  • 0-7: low risk
  • 8-15: risky / hazardous drinking
  • 16-19: harmful drinking
  • 20+: likely alcohol dependence
• Key exam point: A cutoff of 8 is the most widely cited threshold for further assessment in adults. Lower the cutoff to 4 for adolescents and for women over 65, who reach risk at lower consumption.

AUDIT-C

The consumption-only three-item subset of the AUDIT, designed for fast primary-care use.

• Items: 3 (frequency, typical quantity, frequency of heavy drinking).
• Cutoffs: >= 4 in men, >= 3 in women indicate hazardous drinking.
• Often the first screen used in SBIRT workflows because it takes under a minute and is easy to embed in an electronic health record.

CAGE

The classic 4-item alcohol screener — mnemonic C-A-G-E — favored for its brevity in medical settings.

• C — Have you ever felt you should Cut down on your drinking?
• A — Have people Annoyed you by criticizing your drinking?
• G — Have you felt Guilty about your drinking?
• E — Have you ever had an Eye-opener (a drink first thing in the morning)?
• Cutoff: 2 or more 'yes' answers is clinically significant and warrants further assessment.
• Limitation: Detects lifetime better than current use; not validated for adolescents. The CAGE-AID variant adds drugs.

DAST-10 (Drug Abuse Screening Test, 10-item)

• Items: 10 yes/no items covering the past 12 months.
• Substance: Drug use other than alcohol (illicit plus non-medical prescription use).
• Scoring (0-10):
  • 0: no problems reported
  • 1-2: low level
  • 3-5: moderate level — assessment recommended
  • 6-8: substantial
  • 9-10: severe
• Exam point: Pair the AUDIT with the DAST-10 to cover both alcohol and other drugs in adults.

CRAFFT

The gold-standard adolescent screener (ages 12-21), developed at Boston Children's Hospital.

• C — Have you ridden in a Car driven by someone (including yourself) who was using?
• R — Do you use to Relax, feel better, or fit in?
• A — Do you use while Alone?
• F — Do you Forget things you did while using?
• F — Do Family or friends tell you to cut down?
• T — Have you gotten into Trouble while using?
• Cutoff: 2 or more 'yes' answers indicates high risk and the need for further assessment.

MAST (Michigan Alcoholism Screening Test)

• Items: 25 (the original; the Brief MAST has 10 and the SMAST has 13).
• Substance: Alcohol; emphasizes lifetime consequences.
• Cutoff: 5 or more points indicates likely alcohol use disorder; 3-4 suggests further evaluation.
• Useful when: A more detailed lifetime alcohol history is needed than CAGE provides.

SASSI (Substance Abuse Subtle Screening Inventory)

• Format: Adult (SASSI-4) and adolescent (SASSI-A3) versions; roughly 93-100 items.
• Unique feature: Combines face-valid scales (direct admission of use) with subtle scales that detect defensiveness and minimization, making it harder to fake when clients are court-ordered or otherwise motivated to deny use.
• Used for: Forensic, employee-assistance (EAP), and child-welfare populations where under-reporting is expected.

Comparison at a Glance

Know these cutoffs cold — items frequently swap one number to test whether you have memorized the validated threshold rather than guessing.

Matching the Tool to the Population

The exam rarely asks 'what is the AUDIT cutoff' in isolation; it embeds the question in a population. The single most important matching rule is age: for any client described as a teenager or young adult (12-21), the CRAFFT is the answer, because it is the only listed instrument validated for that age group and it covers both alcohol and drugs. For adults whose problem is clearly alcohol, the AUDIT (or its short AUDIT-C subset, or CAGE) is appropriate. When the vignette stresses other drugs — opioids, stimulants, cannabis, non-medical prescriptions — reach for the DAST-10.

When the client has an incentive to lie (court-ordered, custody dispute, fitness-for-duty), the SASSI with its subtle scales is the best fit.

Sensitivity, Specificity, and Cutoffs

A screening cutoff is a deliberate trade-off. Lowering a cutoff raises sensitivity (fewer missed cases) but lowers specificity (more false positives); raising it does the reverse. This is exactly why the AUDIT cutoff drops to 4 for adolescents and older women — populations that experience harm at lower consumption, where missing a case is costlier than over-referring. Understanding this logic lets you reason about an unfamiliar threshold rather than relying purely on memory.

Self-Report Limitations

Every instrument in this table relies on self-report, so all share a common weakness: clients under-report when disclosure carries consequences. Counselors mitigate this with a non-judgmental stance, assurances of confidentiality under 42 CFR Part 2, collateral information, and, where appropriate, the SASSI or toxicology. A screener is a starting point for a conversation, not a lie detector. The exam expects you to treat a low score in a high-suspicion client as a reason to gather collateral and reassess, not to close the file.