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III A.Routine screening methods for substance use

Element Details

Definition:

Programs that provide services to individuals with co-occurring disorders routinely and systematically screen for both substance use and mental health symptoms. The following text box provides a standard definition of “screening” that originates from SAMHSA’s Co-Occurring Measure (2007).

Screening:

The purpose of screening is to determine the likelihood that a person has a co-occurring substance use or mental disorder. The purpose is not to establish the presence or specific type of such a disorder, but to establish the need for an in-depth assessment. Screening is a formal process that typically is brief and occurs soon after the patient presents for services. There are three essential elements that characterize screening: intent, formal process, and early implementation.

  • Intent: Screening is intended to determine the possibility of a co-occurring disorder, not to establish definitively the presence, or absence, or specific type of such a disorder.

  • Formal process: The information gathered during screening is substantially the same no matter who collects it. Although a standardized scale or test need not be used, the same information must be gathered in a consistently applied process and interpreted or used in essentially the same way for everyone screened.

  • Early implementation: Screening is conducted early in a person’s treatment episode. For the purpose of this questionnaire, screening would routinely be conducted within the first four visits or within the first month following admission to treatment.

Source:

Interviews with program leadership and staff, observations of medical record (or electronic medical record system) or intake screening form packets.

Item Response Coding:

Coding of this item requires the evaluation of screening methods routinely used in the program.

  • Mental Health Only Services = (SCORE-1): Pre-admission screening based on patient self-report. Decision based on clinician inference from patient presentation or history. The program has essentially no screening for substance use problems. On occasion, a program at this level offers a minimal screening for substance use disorders, which is based on the clinician’s initial observations and/or impressions.

  • (SCORE-2): Pre-admission screening for substance use and treatment history prior to admission. The program conducts a basic screening for substance use problems prior to admission, but it is not a routine or standardized component of the evaluation procedures (occurs less than 80 percent of the time). At this level, the screen might include some symptom review, treatment history, current medications, and/or abstinence/relapse history. Considerable variability across clinicians occurs at this level.

  • Dual Diagnosis Capable = (SCORE-3): Routine set of standard interview questions for substance use using generic framework (e.g., ASAM-PPC Dim. I & V, LOCUS Dim. III) or “biopsychosocial” data collection. The program conducts a screening process with interview questions for substance use problems; it is incorporated into a more comprehensive evaluation procedure; and it occurs routinely (at least 80 percent of the time). This screening is standardized in that it consists of a standard set of questions or items. The format of the screening questions may be open-ended or discrete, but they are used consistently.

  • (SCORE-4): Screen for substance use using standardized or formal instruments with established psychometric properties. The program conducts a systematic screening process that uses standardized, and reliable and valid instrument(s) for screening for substance use. This screening process is routinely used (at least 80 percent of the time).

  • Dual Diagnosis Enhanced = (SCORE-5): Screen using standardized or formal instruments for both mental health and substance use disorders with established psychometric properties. The program conducts a systematic screening process which uses standardized, reliable, and valid instrument(s) for screening both substance use and mental disorders. This screening process is used routinely (at least 80 percent of the time), incorporated into the comprehensive evaluation procedures, and considered an essential component in directing the individual’s care. If programs routinely use toxicology screening (e.g., such as breath or urine samples) to detect substance use, this would also meet criteria for a standardized measure.
Enhancing MHOS Programs

MHOS programs typically attempt to capture or detect substance use problems via an initial phone interview. This interview typically asks about current and past alcohol or drug use, prior treatment, and if the caller ever received an addiction diagnosis. The responses may be used to refer a patient to a substance use treatment center and may not routinely trigger a substance use assessment.

In order to become DDC, MHOS programs must extend this procedure to routinely screen for current and past substance use problems using a standard set of interview questions. This may be based upon a generic framework (e.g., the ASAM-PPC) or via a broad biopsychosocial assessment.

For more information on screening, an overview of screening and assessment produced by SAMHSA’s Co-Occurring Center for Excellence is available. Screening, Assessment, and Treatment Planning for Persons with Co-Occurring Disorders is online at www.samhsa.gov/co-occurring/topics/screening-and-assessment/samsha-overview.aspx.

Enhancing DDC Programs

In order to achieve the DDE level, DDC programs institute standardized screening measures for both mental health and substance use disorders, and the measures are used them routinely (with at least 80 percent of patients). Standard measures may screen for more general mental health and substance use symptoms, while some are sensitive to specific mental health disorders. Examples include the Modified MINI Screen (MMS), Mental Health Screening Form-III, CAGE-AID, Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD), and the Global Appraisal of Individual Need (GAIN) Short Screener (GAIN-SS). Measures with greater specificity to screen for the most prevalent mental health disorders are also recommended. These may include measures for depression (e.g., Beck Depression Inventory), anxiety (e.g., Beck Anxiety Inventory), PTSD (e.g., Posttraumatic Stress Disorder Checklist), and social phobia (e.g., Social Interaction Anxiety Scale). Key to operating at the DDE level is the implementation and systematic application of a standardized (and psychometrically sound) screening measure(s). If programs routinely use toxicology screening (e.g., such as breath or urine samples) to detect substance use, this would also meet criteria for a standardized measure. Examples of screening measures are available on the References and Downloads page.