National Institute on Alcohol Abuse and Alcoholism No. 12 PH 294 April 1991

Assessing Alcoholism

The goal of assessment is to determine personal characteristics that can influence the treatment of a patient's alcohol problem. Once a person has been referred for alcohol treatment, clinicians use assessment techniques to characterize the problem and to plan treatment (1,2).

Assessment comprises at least four important tasks: 1) to aid in the formal diagnosis of the patient's alcohol problem; 2) to establish the severity of the alcohol problem; 3) to guide treatment planning; and 4) to define a baseline of the patient's status, to which his or her future conditions can be compared (3). Assessment is an ongoing, interactive process, used to evaluate a patient's progress and adjust treatment.

Questions answered by assessment include the following: Can withdrawal be accomplished without medications? Is outpatient treatment appropriate? If inpatient treatment is desirable, should the setting be psychiatric or alcohol-specific in nature? What would be an appropriate mix of choices taken from the variety of therapies? How has the patient's status changed during the course of treatment, and what problem areas remain?

A variety of methods are involved in comprehensive patient assessment, including medical examinations, clinical interviews, and formal instruments (questionnaires or tests). Each has specific strengths, and the approaches complement each other as they address the four goals stated above.

Every patient entering alcoholism treatment presents a unique combination of medical and psychological characteristics (4-7). Clinical interviews are valuable, and it is unlikely that there will ever be an adequate substitute for the experienced and skillful clinician. Nevertheless, the clinician's perception and judgment can be enhanced by the application of formal assessment instruments. Formal instruments relating to alcohol problems can be used to assess beliefs about the effects of drinking, levels of alcohol dependence, high-risk drinking situations, and resources that will aid in recovery. General psychological instruments can be used to assess personality, cognition, and neuropsychological characteristics.

Most alcoholism assessment instruments are standardized, self-administered questionnaires (or tests). These instruments offer comprehensiveness, consistency, ease of administration, and low cost. Standardized instruments provide a quantitative scale of alcohol problems, which can be useful, for example, when attempting to measure the patient's current need for treatment and future progress. In addition, formal instruments tend to be highly valid (they measure meaningful dimensions of alcoholism) and reliable. They also offer the clinician norms, by which the patient can be quantitatively compared to peers. And finally, some patients may place greater confidence in treatment strategies based on results of standardized tests rather than on clinical judgment alone.

Clinicians can choose from more than 100 assessment instruments in constructing a battery of tests tailored to the needs of a particular patient (see, for example, 8-14). Some instruments are protected by copyright, but can be obtained and used by paying a small royalty fee. Many are available free of charge.

To make a formal diagnosis of alcoholism, the clinician might use a test such as the alcohol section of the Structured Clinical Interview for DSM-III-R (SCID). The SCID is an extensive interview which must be administered by a trained clinician. The alcohol section of the SCID can be administered in about 15 minutes. The SCID reflects the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) to arrive at a formal diagnosis (15). To make a quick estimate of the patient's psychiatric condition, the clinician might employ a short screening instrument such as the Brief Psychiatric Rating Scale, or BPRS, which can be administered in about 5 minutes (16). Should the BPRS suggest possibly severe psychiatric problems, the clinician might then administer the SCID in its entirety.

To establish the severity of the patient's alcohol problem, the clinician might use an instrument such as the Addiction Severity Index, or ASI (9). The ASI is a structured, 40-minute interview designed to assess the severity of adjustment problems in seven areas: medical, legal, psychiatric, drug abuse, alcohol abuse, employment, and family. The patient answers questions related to the number, extent, and duration of difficulties in each of these areas.

To help individualize treatment, the clinician might employ an instrument such as the Alcohol Use Inventory, or AUI (8,17). The AUI assesses the patient on the basis of three domains: perceived benefits of drinking, drinking styles, and consequences of drinking. Answers to test questions in these domains offer helpful suggestions in planning treatment. A recent version of the AUI comprises 228 questions, and can be self-administered in 40 to 60 minutes.

While some patients require medication to help them withdraw from alcohol, many others do quite well with the assistance of social support, emotional reassurance, and frequent "reality reorientation." The Clinical Institute Withdrawal Assessment Scale (CIWA) is an example of an instrument designed to help clinicians choose the best strategies for treating the patient's withdrawal (10,18). The CIWA employs a "check off" format to uncover signs and symptoms of alcohol withdrawal. Two recent studies found the CIWA to be helpful in identifying the risk of severe withdrawal and the need for medication (19,20).

A growing area of interest in alcoholism treatment deals with identifying emotional, cognitive, and social factors that may precipitate drinking. If such prompting, or "high risk," circumstances can be accurately gauged, treatment can incorporate interventions to teach the patient the skills to cope with them. The Inventory of Drinking Situations (21) and the Alcohol Expectancy Questionnaire (22) are examples of promising instruments being used in this area.

To establish a baseline to which future improvement or deterioration of the patient may be compared, the clinician might use an instrument such as the ASI, noted earlier. The measures cited here are examples of a wide range of instruments, some or all of which might be helpful to patients.

Many factors must be considered in choosing and employing assessment instruments to obtain treatment-relevant information (23). In the course of treatment, the timing and sequencing of tests are important issues. For example, an early test might help determine if the patient will require detoxification. Subsequent tests might assess collateral or contributing psychological problems and suggest interventions and treatment. Later tests might measure the progress of the patient and assist in selection of after-care interventions.

Many patients will show cognitive improvement during the few weeks after drinking has stopped, in which case the clinician must be especially alert to the timing of tests. In addition, certain limitations of patients will affect the administration of tests--indeed, the greater the patient's impairment, the greater the demand for skill on the part of the interviewer. The timing and selection of tests depends not only on the course of the patient's progress, but also on the needs of the treatment facility. In choosing and using instruments, administrators and clinicians consider cost, staff capacity, and their own treatment models.

Assessment techniques can provide benefits other than those for which they a re specifically designed. For example, the administration of instruments can suggest the seriousness and concern for individual patients of a program. This can encourage patients to stay with or return to treatment (2,24).

Assessing Alcoholism--A Commentary by
NIAAA Director Enoch Gordis, M.D.

Assessment is a valuable tool for alcoholism treatment, and the use of formal assessment instruments as a standard part of all alcoholism treatment programs is recommended.

Although formal assessment cannot replace an experienced clinician's judgment, standardized tests and questionnaires can supplement clinical wisdom in important ways. For example, an assessment instrument can provide important baseline data for measuring individual patient progress, can aid in making patient/treatment-match decisions, or, in the press of a busy day, can help prevent clinical staff from omitting things of importance at intake. Even programs in which only one mix of treatment is offered can use formal assessments to highlight aspects of a patient's life that need the most help. Formal assessment also can provide standardized patient outcome data that can be used to justify reimbursement and validate the effectiveness of program components.

The number of programs that currently use any type of assessment instrument is low, although there are many advantages to such use. Many programs are concerned that using an assessment instrument may require extensive staff training or time that should be spent in patient care. However, all competent programs perform some kind of assessment, whether it involves a clinician's initial interview with a patient or the use of a formal assessment instrument. In many cases, a portion of the time currently used to conduct initial patient interviews can be devoted to formal assessment without interfering with patient care. Moreover, the variety of instruments that are now available permits a program to tailor assessment to its individual staff and schedule.

References

(1) ALLEN, J.P.; Eckardt, M.J.; and Wallen, J. Screening for alcoholism: Techniques and issues. Public Health Reports 103(6):586-592, 1988.(2) Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990.(3) SOBELL, L.C.; Sobell, M.B.; and Nirenberg, T.D. Behavioral assessment and treatment planning with alcohol and drug abusers: A review with an emphasis on clinical application. Clinical Psychology Review 8:19-54, 1988.(4) MCLELLAN, A.T.; Luborsky, L.; Woody, G.E.; O'Brien, C.P.; and Druley, K.A. Predicting response to alcohol and drug abuse treatments: Role of psychiatric severity. Archives of General Psychiatry 40(6):620-625, 1983.(5) MCLELLAN, A.T.; Woody, G.E.; Luborsky, L; O'Brien, C.P.; and Druley, K.A. Increased effectiveness of substance abuse treatment: A prospective study of patient-treatment "matching." Journal of Nervous and Mental Disease 171(10):597-605. 1983.(6) WANBERG, K.W., & Horn, J.L. Assessment of alcohol use with multidimensional concepts and measures. American Psychologist 38(10):1055-1069, 1983.(7) JACOBSON, G.R. A comprehensive approach to pretreatment evaluation: I. Detection, assessment, and diagnosis of alcoholism. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches. New York: Pergamon Press, 1989. pp. 17-43.(8) WANBERG, K.W.; Horn, J.L.; and Foster, F.M. A differential assessment model for alcoholism: The scales of the Alcohol Use Inventory. Journal of Studies on Alcohol 38(3):512-543, 1977.(9) MCLELLAN, A.T.; Luborsky, L.; Woody, G.E.; and O'Brien, C.P. An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disease 168(1):26-33. 1980.(10) SHAW, J.M.; Kolesar, G.S.; Sellers, E.M.; Kaplan, H.L.; and Sandor, P. Development of optimal treatment tactics for alcohol withdrawal. I. Assessment and effectiveness of supportive care. Journal of Clinical Psychopharmacology 1(6):382-387, 1981.(11) MILLER, W.R., & Marlatt, G.A. Manual for the Comprehensive Drinker Profile. Odessa, FL: Psychological Assessment Resources, Inc., 1984.(12) LETTIERI, D.J.; Sayers, M.A.; and Nelson, J.E., eds. Treatment Handbook Series 2: Alcoholism Treatment Assessment Research Instruments. National Institute on Alcohol Abuse and Alcoholism. Division of Extramural Research. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1985.(13) WINTERS, K.C., & Henly, G.A. Personal Experience Inventory. Los Angeles: Western Psychological Services, 1989.(14) ROSS, H.E.; Gavin, D.R.; and Skinner, H.A. Diagnostic validity of the MAST and the Alcohol Dependence Scale in the assessment of DSM-III alcohol disorders. Journal of Studies on Alcohol, in press.(15) JACOBSON, G.R. A comprehensive approach to pretreatment evaluation: II. Other clinical considerations. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches. New York: Pergamon Press, 1989. pp. 54-66.(16) LYLERLY, S.B., & Abbott, P.S., eds. Handbook of Psychiatric Rating Scales (1950-1964). Public Health Service Pub. No. 1495. Washington, DC: Department of Health, Education, and Welfare, 1964.(17) HORN, J.L.; Wanberg, K.W.; and Foster, F.M. Guide to the Alcohol Use Inventory. Minneapolis: National Computer Systems, 1987.(18) LITTEN, R.Z., & Allen, J.P. Pharmacotherapies for alcoholism: Promising agents and clinical issues. Alcoholism: Clinical and Experimental Research, in press.(19) ADINOFF, B.; Bone, G.H.A.; and Linnoila, M. Acute ethanol poisoning and ethanol withdrawal syndrome. Medical Toxicology 3:172-196, 1988.(20) FOY, A.; March, S.; and Drinkwater, V. Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcoholism: Clinical and Experimental Research 12(3):360-364, 1988.(21) ANNIS, H.M.; Graham, J.M.; and Davis, C.S. Inventory of Drinking Situations User's Guide. Toronto: Addiction Research Foundation, 1987.(22) BROWN, S.A.; Goldman, M.S.; Inn, A.; and Anderson, L.R. Expectations of reinforcement from alcohol: Their domain and relation to drinking patterns. Journal of Consulting and Clinical Psychology 48:419-426, 1980.(23) MAISTO, S.A., & Connors, G.J. Clinical diagnostic techniques and assessment tools in alcohol research. Alcohol Health & Research World, in press.(24) ANNIS, H.M., & Davis, C.S. Relapse prevention. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches. New York: Pergamon Press, 1989. pp. 170-182.

Representative Sources for Assessment Instruments:

(1) Marketing Services, Department 898, Addiction Research Foundation, 33 Russell St., Toronto, Ontario, Canada M5S2S1.(2) Psychological Assessment Resources, Inc., 16204 North Florida Ave., Lutz, FL 33549-6130.(3) Western Psychological Services, 12031 Wilshire Blvd., Los Angeles, CA 90025-1251.

All material contained in the Alcohol Alert is in the public domain and may be used or reproduced without permission from NIAAA. Citation of the source is appreciated.

Copies of the Alcohol Alert are available free of charge from the Scientific Communications Branch, Office of Scientific Affairs, NIAAA, Willco Building, Suite 409, 6000 Executive Boulevard, Bethesda, MD 20892-7003. Telephone: 301-443-3860.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service * National Institutes of Health