Addiction Severity Index 5th Edition

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Tom McLellan & Deni CariseTreatment Research Institute www.tresearch.orgUNODC Treatnet ASI Version 2.9

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30 December 2006

LIST OF COMMONLY USED DRUGS:

Alcohol: Beer, wine, liquor, grain (methyl alcohol) Heroin: Smack, H, Horse, Brown Sugar Methadone: Dolophine, LAAM

Remember: This is an interview, not a test International Standard Classification of Occupations

1. Legislators, officials Main tasks are forming government policies, laws, regulations and overseeing implementation.

2. Professionals - Requires high level of professional knowledge in the fields of physical and life sciences, or social sciences/humanities.

3. Technicians /assoc. professionals - Requires technical knowledge, experience in fields of physical, life or social sciences, humanities.

4. Clerks - Performs secretarial duties, word processing and other customer-oriented clerical duties.

5. Service & Sales - Includes services related to travel, catering, shop sales, housekeeping, and maintaining law and order.

6. Skilled agricultural and fishery workers - Consists of growing crops, breeding or hunting animals, catching or cultivating fish, etc.

7. Craft & Trades - Main tasks consist of constructing buildings and other structures, making various products. Includes handicrafts.

8. Plant and machine operators - Main tasks consist of driving vehicles, operating machinery, or assembling products.

9. Elementary Occupations Includes simple and routine tasks, such as selling goods in streets, doormen, cleaning, and working laborers.

0. Armed forces - Includes army, navy, air force workers, etc. Excludes non-military police, customs, inactive military reserves.

INTRODUCING THE ASI:

1. All clients receive this same standard interview.

2. Seven Potential problem areas or Domains: Medical, Employment/Support Status, Alcohol, Drug, Legal, Family/Social, and Psychiatric.

3. The interview will take about 30-40 minutes.

4. Patient Rating Scale: Patient input is important. For each area, I will ask you to use this scale to let me know how bothered you have been by any problems in each section. I will also ask you how important treatment is for you for the area being discussed.

The scale is:

0 - Not at all

1 Slightly

2 Moderately

3 Considerably

4 Extremely

5. All information gathered is confidential

6. Accuracy - You have the right to refuse to answer any question, if you are uncomfortable or feel it is too personal or painful to give an answer, just tell us, I want to skip that question. Wed rather have no answer than an inaccurate one!

7. There are two time periods we will discuss:

1. The past 30 days

2. Lifetime INTERVIEWER INSTRUCTIONS:

1. Leave no blanks.

2. Make plenty of Comments (if another person reads this ASI, they should have a relatively complete picture of the client's perceptions of his/her problems). When noting comments, please write the question number. Probe and clarify!

3. X = Question not answered. Client cannot or will not answer.

4. N = Question not applicable. Must have instructions in item to use N

5. End the interview if client misrepresents or cannot understand after two or more sections.

6. Half Time Rule!

If a question asks the number of months, round up periods of 14 days or more to 1 month. Round up 6 months or more to 1 year.

7. Hints and clarification notes in the ASI are bulleted "x".

Probe, cross-check and make plenty of comments! Opiates:Opium, Fentanyl, Buprenorphine, pain killers - Morphine, Dilaudid, Demerol, Percocet, Darvon, etc.

Barbiturates:Nembutal, Seconal, Tuinal, Amytal, Pentobarbital, Secobarbital, Phenobarbital, Fiorinal, Doriden, etc.

Sed/Hyp/Tranq: Benzodiazepines = Valium, Librium, Ativan, Serax Tranxene, Dalmane, Halcion, Xanax, Miltown, Other = Chloral Hydrate, Quaaludes

Cocaine: Cocaine Crystal, Free-Base Cocaine, Crack, Rock, etc. Amphetamines/: Monster, Crank, Benzedrine, Dexedrine, Ritalin, Stimulants Preludin, Methamphetamine, Speed, Ice, Crystal, Khat Cannabis: Marijuana, Hashish, Pot, Bango Igbo, Indian Hemp,

Bhang, Charas, Ganja, Mota, AnashaHallucinogens:LSD (Acid), Mescaline, Psilocybin (Mushrooms), Peyote, PCP, MDMA, Ecstasy, Angel Dust

Inhalants:Nitrous Oxide (Whippits), Amyl Nitrite (Poppers), Glue, Solvents, Gasoline, Toluene, Etc.

ALCOHOL/DRUG USE INSTRUCTIONS:

The following questions refer to two time periods: the past 30 days and lifetime. Lifetime refers to the time prior to the last 30 days.

30 day questions only require the number of days used.

Lifetime use is asked to determine extended periods of regular use.

Regular use =

1. Three or more times per week

2. Binges

3. Problematic irregular use

Ask these questions with the following sentence stems -

o How many days in the past 30 have you used....?

o "How many years in your life have you regularly used....?"

D2. Alcohol to intoxication does not necessarily mean "drunk", use the words to where you felt the effects", got a buzz, high, etc. instead of

intoxication. As a rule, 3 or more drinks in one sitting, 4 or more drinks in one day for women (5 or more for men) is coded under intoxication" to designate heavy drinking

G1. Patient ID Susan Olin

G2.Country G2a. Center

G2b.Program . G2c. Modality

See Back Page of ASI for Country, Center and Program Listings

G3. Will this treatment be delivered in a corrections facility? 1

0=No 1= Yes

G4. Date of Admission 04 /12 2015 /

*Day / Month / Year

G5. Date of Interview: 15/ /1/ 2016

G6 Time Begun: (Hour: Minutes) 11:30 a.m :

G7. Time Ended: (Hour:Minutes) 1.00 p.m0. p.m: US TT GENERAL INFORMATION

G2c. Modality Codes:

1=Outpatient (<5 hours per week)

2=Intensive Outpatient ( 5 hours per week)

H 4 3=Residential/Inpatient

4=Therapeutic Community

5=Half-way house

6=Detox Inpatient (typically 3 7 days)

7=Detox Outpatient/Ambulatory

8=Opioid Replacement, outpatient (Methadone, Buprenorphine, etc)

9=Other (low threshold, GP, spiritual healers, etc.)

PROBLEMS SEVERITY PROFILE

0 1 2 3 4 5 6 7 8 9

MEDICAL - 6 EMP/SUP 3 ALCOHOL 4 DRUGS LEGAL 3 FAM/SOC 4 PSYCH 7 Specify

pmG8. Class: 1. Intake 2. Follow-up

G9. Contact Code: 1. In person

2. Telephone (Intake ASI must be in person)

GENERAL INFORMATION COMMENTS

(Include the question number with your notes)

G10. Gender: 1. Male 2. Female

G11. Interviewer Code No./ Initials: SO Who referred you to treatment? (Provide details):

The mother of the patient referred her for treatment

Name

Susan Olin

G14. How long have you lived at this address? 15 / Years Months

Day Month Year

G16. Date of birth: 19/8 16a. Age 16 years Years old 1990

G17. What race/ethnicity/nationality do you consider yourself?

Specify American

G18. Do you have a religious preference?

G18, if coded Other, specify_ 2

1. Protestant 4. Muslim 7. Hindu

2. Catholic 5. Other Christian 8. Buddhist

3. Jewish 6. None 9. Other (specify in comments)

G19. Have you been in a controlled environment in the past 30 days?

1. No 4. Medical Treatment 2. Correctional Facility 5. Psychiatric Treatment

3. Alcohol/Drug Treat. 6. Other: xA place, theoretically, without access to drugs/alcohol.

G20. How many days? N/A

x If G19=No, G20= NN Refers to total number of days detained in the past 30 days.

Page 1

Treatnet ASI

M1. How many times in your life have you been hospitalized for medical problems? N/A

x Include O.D.'s and D.T.'s. Exclude detox, alcohol/drug, psychiatric treatment and childbirth (if no complications).

Enter the number of overnight hospitalizations for medical problems. M12. Have you ever been tested for hepatitis? 0

0 = No, 1=Yes

M12a. If Yes, what was the result? N/A

1 = Hep Negative (not infected)

2 = Hep positive (infected)

3 = Dont Know

x If M12=No, M12a =N

M12b. Would you like help obtaining a Hepatitis test? NO

M13. Have you ever been tested for HIV? 1

0 = No, 1=Yes

M13a. If Yes, what was the result? 1

1 = HIV Negative (not infected)

2 = HIV positive (infected)

3 = Dont Know

x If M13=No, M13a = N

M13b. Would you like help obtaining an HIV test?

M3. Do you have any chronic medical 0=No 1=Yes

problems which continue to interfere with your life?

x If "Yes", specify in comments.

x A chronic medical condition is a serious physical condition that requires regular care, (i.e., medication, dietary restriction) preventing full advantage of their abilities.

0=No 1=Yes

M4. Has a health care provider recommended you take any medications on a regular basis for a physical problem? YES

x Do not include various remedies given by a non-healthcare

Provider .Must be for a medical condition; dont

include psychiatric medicines. Include medicines prescribed whether or not the patient is currently taking them.

The intent is to verify chronic medical problems.

M5. Do you receive financial support for a physical disability? 0

0 - No 1 - Yes

x If Yes, specify in comments.

x Include Workers' compensation, early retirement for medical

Disability. Exclude psychiatric disability. India code X If patient is Male, code all N 0=No, 1=Yes, 2=Unsure

M14. Are you currently pregnant?

M14a. If pregnant; do you have prenatal care? M14b. If unsure; would you like help obtaining

a pregnancy test?

x If M14= 0 or 2 (No or Unsure), M14a = N

x If M14= 1 (Yes), M14b = N MEDICAL COMMENTS

(Include question number with your notes)

MEDICAL STATUS

Treatnet ASI

The patient usually feels uncomfortable

M6. How many days have you experienced medical problems in the past 30 days? 22 days

x Include flu, colds, injuries, etc. Include serious ailments related to drugs/alcohol, which would continue even if the patient were abstinent (e.g., cirrhosis of liver, HIV, HCV, HBV abscesses from needles, etc.).

For Questions M7 & M8, ask the patient to use the Patient Rating scale.

M7. How troubled or bothered have you been by these medical problems in the past 30 days? for

x Restrict response to problem days of Question M6.

M8. How important to you now is treatment for

these medical problems? x If client is currently receiving medical treatment, refer to the need for additional medical treatment by the patient.

Note: The patient is rating their need for additional medical services or referrals from your agency, above any services they may already be getting.

CONFIDENCE RATINGS

Is the above information significantly distorted by:M10. Patient's misrepresentation? 0 - No 1 - Yes

When she has not taken any drugs

M11. Patient's inability to understand? 0 - No 1 - Yes

Page 2

EMPLOYMENT/SUPPORT STATUS

E1. Education completed:

x Code Years and Months, Level # or both.

*Level 0 = No education

* Level 1 = Primary 1-6 yrs Yrs. Mos.

* Level 2 = Lower Secondary 7-9 yrs* Level 3 = Upper Secondary 10-12 yrs* Level 4 = Post Secondary, non-tertiary OR

(addl preparation for level 5) Code Level #

* Level 5 = First Stage Tertiary

(+4 -6 years, incl BS, MS)

* Level 6 = Second Stage Tertiary (include doctorate, etc).

x Include formal education only.

E1a. Highest degree earned, specify

E2. Training or Technical education completed: Still in College

Treatnet ASI EMPLOYMENT/SUPPORT COMMENTS

(Include question number with your notes)

x Formal/organized training only. Months

E4a. Are your job options limited by lack of tr...

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