Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
The WHO ASSIST project aims to support and promote screening and brief
interventions for psychoactive substance use by health professionals to
facilitate prevention, early recognition and management of substance use
disorders in health care systems with the ultimate goal of reducing the The Alcohol, Smoking and Substance
disease burden attributable to psychoactive substance use worldwide.
Involvement Screening Test (ASSIST)
Manual for use in primary care
The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in pri-
mary care / prepared by R. Humeniuk [et al].
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press,
World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264;
fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or trans-
late WHO publications whether for sale or for noncommercial distribution should be addressed
to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the
expression of any opinion whatsoever on the part of the World Health Organization concerning the
legal status of any country, territory, city or area or of its authorities, or concerning the delimitation
of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which
there may not yet be full agreement.
The mention of specific companies or of certain manufacturers products does not imply that
they are endorsed or recommended by the World Health Organization in preference to others of
a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the informa-
tion contained in this publication. However, the published material is being distributed without
warranty of any kind, either expressed or implied. The responsibility for the interpretation and use
of the material lies with the reader. In no event shall the World Health Organization be liable for
damages arising from its use.
The named authors alone are responsible for the views expressed in this publication.
Printed in France.
ConTenTS III
Contents
Acknowledgements iv
1 Purposeofthemanual 1
2 WhatistheASSIST? 2
3 DevelopmentoftheASSISTandlinkedbriefintervention 4
4 Rationaleforscreeningforsubstanceuse 6
5 WhocanusetheASSIST? 7
6 Whichclientsshouldbescreened? 8
7 Problemsrelatedtosubstanceuse 9
8 Specifichealthproblemsfromindividualsubstances 11
9 ConsideringtheclientwhenadministeringtheASSIST 19
10TheASSISTintroduction 20
11 GoodpracticeinASSISTquestionnaireadministration 22
12HowtoadministertheASSISTquestionnaire 24
13ScoringoftheASSISTquestionnaire 32
14InterpretationofASSISTscores 34
15LinkingASSISTscoreswithtreatment 35
16 HowtoincludescreeningwiththeASSISTineverydaypractice 37
17Guidetoappendices 41
Appendices
A TheAlcohol,SmokingandSubstanceInvolvementScreeningTest(ASSISTv3.1) 42
B ASSISTv3.1responsecard 48
C ASSISTv3.1feedbackreportcard 49
D ASSISTrisksofinjectingcard Informationforclients 53
E Translationandadaptationtolocallanguagesandculture:
aresourceforcliniciansandresearchers 54
F Answerstoself-testingquestionsfromChapter11 55
G Twoclientscripts( ChloeandDave) 56
ClientscriptASSISTv3.1(Chloe) Responsesforpairedroleplay 57
ClientscriptASSISTv3.1(Dave) Responsesforpairedroleplay 62
References 67
Iv ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
Acknowledgements
This manual was developed in the framework of the WHO ASSIST Project, coordinated, sponsored
and implemented by the WHO Department of Mental Health and Substance Abuse, Management
of Substance Abuse.
This manual was written by R. Humeniuk, S. Henry-Edwards, R. Ali, V. Poznyak and M. Monteiro.
The initial draft for field testing was produced in the framework of Phase III of the WHO ASSIST
project. The following experts, members of the WHO ASSIST Phase III Working Group, made
valuable contributions to the first draft of the manual: Tomas Babor (USA), Michael Farrell (UK),
Maria Lucia Formigoni (Brazil), Roseli Boerngen de Lacerda (Brazil), Walter Ling (USA), John Marsden
(UK), Jose Martinez -Raga (Spain), Bonnie McRee (USA), David Newcombe (Australia), Hemraj Pal
(India), Sara Simon (USA), Janice Vendetti (USA). The preparation of the draft manual for field test-
ing and its further development was coordinated by Vladimir Poznyak and Maristela Monteiro from
the WHO Department of Mental Health and Substance Abuse and Rachel Humeniuk and Robert Ali
from Drug and Alcohol Services South Australia, WHO Collaborating Centre for Research in the
Treatment of Drug and Alcohol Problems (Australia).
The revision of the draft manual for field testing was undertaken by Robert Ali and Sonali Meena
(Australia) with the valuable contributions from the following members of the WHO ASSIST
Advisory Committee and other experts: Thomas Babor (USA), Carina Ferreira-Borges (WHO AFRO),
Alexandra Fleischmann (WHO), Maria Lucia Formigoni (Brazil), Walter Ling (USA), Hem Raj Pal
(India), Rick Rawson (USA).
Finalization of the manual and its production was coordinated by Vladimir Poznyak (WHO) with the
assistance from Rachel Humeniuk, Sonali Meena and Lidia Segura (Spain). Administrative support
was provided by Tess Narciso and Mylne Schreiber.
Suggested citation: Humeniuk RE, Henry-Edwards S, Ali RL, Poznyak V and Monteiro M (2010). The
Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary
care. Geneva, World Health Organization.
Humeniuk RE, Henry-Edwards S, Ali RL, Poznyak V and Monteiro M (2010). The ASSIST-linked brief
intervention for hazardous and harmful substance use: manual for use in primary care. Geneva,
World Health Organization.
Humeniuk RE, Henry-Edwards S, Ali RL and Meena S (2010). Self-help strategies for cutting down or
stopping substance use: a guide. Geneva, World Health Organization.
The development and production of the manual and implementation of the WHO ASSIST
Project has been made possible thanks to the financial support of the Australian Commonwealth
Department of Health and Aging and the Government of Valencia, Spain.
1 PurPoSe of The MAnuAl 1
1 Purpose of
the manual
rationale for screening and brief intervention; Appendix F provides answers to the self-
testing questions posed in Chapter 11
problems related to substance use; Good practice in ASSIST questionnaire
the development and validation of the ASSIST; administration.
how to use the ASSIST (administration, scor- Appendix G provides two scripted ASSIST
ing and interpretation of scores); examples for practice in role play.
2 What is
the ASSIST?
The Alcohol, Smoking and Substance appropriate intervention for that level of use
Involvement Screening Test (ASSIST) was (no treatment, brief intervention or referral
developed under the auspices of the World to specialist assessment and treatment
Health Organization (WHO) by an international respectively).
group of addiction researchers and clinicians
in response to the overwhelming public health The ASSIST obtains information from clients
burden associated with psychoactive substance about lifetime use of substances, and use of
use worldwide3, 4, 5. It was designed to be substances and associated problems over the last
used in primary health care settings where 3 months. It can identify a range of problems
hazardous and harmful substance use among associated with substance use including acute
clients may go undetected, or become worse. intoxication, regular use, dependent or high
risk use and injecting behaviour.
The ASSIST (version 3.1) is an 8 item
questionnaire designed to be administered by a In brief the ASSIST comprises the following
health worker to a client using paper and pencil, questions:
and takes about 5-10 minutes to administer. The Question 1 (Q1) asks about which substances
ASSIST was designed to be culturally neutral and have ever been used in the clients lifetime.
useable across a variety of cultures to screen for
use of the following substances: Question 2 (Q2) asks about the frequency of
substance use in the past three months, which
tobacco products
gives an indication of the substances which
alcohol are most relevant to current health status.
cannabis
Question 3 (Q3) asks about the frequency
cocaine of experiencing a strong desire or urge to use
amphetamine-type stimulants (ATS) each substance in the last three months.
sedatives and sleeping pills (benzodiazepines) Question 4 (Q4) asks about the frequency of
hallucinogens health, social, legal or financial problems relat-
inhalants ed to substance use in the last three months.
Question 8 (Q8) asks whether the client has behaviour (Q8) is a particularly high risk activity
ever injected any substance and how recently associated with increased likelihood of over-
that occurred. dose, dependence, infection with bloodborne
viruses such as HIV and hepatitis C and with
The ASSIST v3.1 questonnaire can be found in higher levels of other drug related problems.
the Appendix A, and more information about If a client has been frequently injecting in the
how to administer it and ask each question can last 3 months then they may require referral
be found in Chapter 12 on How to administer to specialist assessment and treatment. More
the ASSIST questionnaire. Two scripted prac- information on this is provided in Chapters 14
tice examples for role play also are provided in and 15 of this manual.
Appendix G.
The development of the ASSIST builds on In 1997 WHO developed the ASSIST to:
previous work by WHO to advance alcohol
be faster to administer than existing diagnos-
screening and brief intervention through the
tic tests for substance use and substance use
development, validation and promotion of
disorders;
the Alcohol Use Disorders Identification Test
(AUDIT) 6, 7, 8. The success of the AUDIT project screen for all psychoactive substances, not
in promoting alcohol screening and brief just alcohol or tobacco;
intervention and its effectiveness in reducing
be able to be used in Primary Health Care
alcohol-related problems in primary health care
settings;
settings provided the impetus for the extension
of screening and brief intervention to other have cross cultural relevance;
substances and related problems, and the
be able to link easily into a brief intervention.
methods used provided a model for the WHO
ASSIST project9. The ASSIST has been through three main
phases of testing to ensure that it is a reliable
The limitations of using existing screening tests
and valid instrument in international settings,
in primary care settings have recently been
and able to link into a brief intervention.
outlined by McPherson and Hersh (2000)10 and
Babor (2005)11. Many existing instruments, Phase I of the WHO ASSIST project was
such as the Addiction Severity Index (ASI)12, conducted in 1997 and 19983. It involved
and expanded Substance Abuse Module of the the development of the first version of the
Composite International Diagnostic Interview ASSIST (version 1.0). The draft questionnaire
(CIDI-SAM)13 although comprehensive, are time had 12 items. The reliability and feasibility of
consuming to administer in primary care set- the questionnaire items were assessed in a
tings. On the other hand, some of the briefer test-retest reliability study which was carried
instruments available, such as the CAGE- out in Australia, Brazil, India, Ireland, Israel, the
Adapted to Include Drugs (CAGE-AID)14, have Palestinian Self-Rule Areas, Puerto Rico, the
a focus on dependence, which is less useful United Kingdom of Great Britain and Northern
for detecting harmful or hazardous use in non- Ireland and Zimbabwe. The sites were chosen
dependent persons. Moreover, the available to ensure that study participants would be
self-report screening tests have a number of culturally diverse and have different substance
limitations from a cross-cultural perspective. use patterns. The results showed that the
Most were developed in the United States of ASSIST had good reliability and feasibility, and
America and do not have demonstrated sen- was revised to an 8 item questionnaire (version
sitivity and specificity for use in other cultures 2.0) on the basis of feedback from the study
and have not been extensively validated. participants to ensure that all items were easy
to administer and understand.
3 develoPMenT of The ASSIST And lInked brIef InTervenTIon 5
Phase II of the project was an international The study was conducted between 2003 and
study to validate the ASSIST questionnaire 2007 in Australia, Brazil, India and the USA.
in a variety of primary health care and drug The brief intervention lasted between 5 and
treatment settings. Validity investigates 15 minutes and was based on the FRAMES
whether a test is measuring the constructs model17 and incorporated Motivational
and conditions intended to be measured. Interviewing techniques18. It focused on the
The study took place during 2000 and 2002 delivery of personalised feedback regarding the
and was carried out in Australia, Brazil, India, participants ASSIST scores and associated risk
Thailand, the United Kingdom, the United through the use of a purpose-designed ASSIST
States of America and Zimbabwe. Participants feedback report card (see Appendix C). The brief
were recruited from both primary care and intervention was bolstered with take-home
alcohol and drug treatment services to ensure self-help information19. The results showed
that individuals with different substance that participants receiving a brief intervention
use patterns were adequately represented. for illicit substances had significantly reduced
The study demonstrated that the ASSIST ASSIST scores after 3 months compared with
had good concurrent, construct, predictive control participants who did not receive a
and discriminant validity, including the brief intervention for their substance use.
development of cut-off scores for lower, Moreover, over 80% of participants reported
moderate and high risk3, 15, 16. The resulting attempting to cut down on their substance use
questionnaire ASSIST v3.0 was finally revised after receiving the brief intervention and also
to the ASSIST v3.1 for clinical use in health and provided positive comments on the impact of
welfare settings whereas the version 3.0 is the brief intervention5.
advised to be used for research purposes.
A pilot study also conducted at the same Information on how to link a brief intervention
time demonstrated that participants recruited into ASSIST scores can be found in The
from primary health care settings did reduce ASSIST-linked brief intervention for hazardous
their substance use if given a brief intervention and harmful substance use: manual for use in
related to their ASSIST scores. primary care1.
There is a significant public health burden hazardous way that may be creating harms,
attributable to psychoactive substance use including the risk of progressing to dependence.
worldwide. Estimates from 2004, indicate that
tobacco, alcohol and illicit drugs account for Screening aims to detect health problems or
8.7%, 3.8% and 0.4% of all deaths respectively, risk factors at an early stage before they have
and 3.7%, 4.5% and 0.9% of Disability caused serious disease or other problems, and is
Adjusted Life Years (DALYs) lost respectively. part of maintaining prevention practice activities
According to the 2009 Global Health Risks in health care settings23, 24. The WHO has identi-
report, substance use is among the top 20 risk fied a number of criteria for deciding which
factors for death and disability worldwide20. medical conditions are suitable for screening
Hazardous and harmful alcohol and other (see Box 1).
substance use also are risk factors for a wide
Hazardous and harmful use of psychoactive
variety of social, financial, legal and relationship
substances meets all these criteria and screen-
problems for individuals and their families.
ing for substance use can be seen as an exten-
Globally, there is an increasing trend for people
sion of existing screening activities in primary
to use multiple substances, either together or at
health care.
different times, which is likely to further increase
the risks.
BOx 1 | Criteria for screening
Substance use and associated risks fall on a
continuum ranging from lower risk (occasional The condition is a significant problem affecting
or non-problematic use) to moderate risk the health and wellbeing of individuals and
the community.
(more regular use) to high risk (frequent
high-risk use). High risk or dependent users There are acceptable treatments or interventions
are more easily identified by clinicians than available for clients who screen positive.
those at lower or moderate risk from their Early identification and intervention leads to
substance use. While it is clear that dependent better outcomes than later treatment.
use is associated with a significant burden of There is a suitable screening test available
disease, there is also evidence that the burden which is acceptable to clients.
on health care systems from non-dependent, The screening test must be available at a
but harmful or hazardous use, may be greater reasonable cost.
than the burden due to dependent use21, 22.
Accordingly, the ASSIST questionnaire has been
designed specifically to identify and intervene
with people who are using substances in a
5 Who CAn uSe The ASSIST 7
6 Which clients
should be screened?
The ASSIST can be used in a number of ways and content of the current instrument as well
to assess clients substance use. In an ideal as the cut-off scores that determine whether
world, all primary health care clients would be a client is lower, moderate or high risk may
screened annually for substance use as part not be appropriate for use with adolescents.
of a health promotion screening programme. For example, an adult who consumes alcohol
This is particularly important for settings where at low-risk levels on a weekly basis would score
a higher proportion of clients are likely to be within the lower risk category. An adolescent
substance users compared with the rest of person drinking at these same levels may be at
the community. For example, university health greater health and social risks and yet still be
services, sexually transmitted disease clinics, scoring within the lower risk category.
districts with a high prevalence of sex workers,
mental health services, prisoner assessment
BOx 2 | Who to screen
programs and primary health services in other
locations with a high prevalence of substance Ideally, all clients in a health promotion
use (see Box 2). If health workers screen screening programme commencing in young
only those they think are likely to have a adulthood.
substance use problem, they may miss clients Primary care and other health care settings
with hazardous and harmful substance use. likely to have a high proportion of substance
Guidelines for how to set up a screening users e.g. STD clinics, university health
programme in health settings are presented services, health services in areas with high
proportions of sex workers and mental health
later in this manual. settings.
Substance use generally commences during Clients whose presenting complaint suggests
adolescence and this period can be seen as a it is/may be related to substance use.
critical milestone for substance use problems New prisoners, particularly those whose
and an appropriate time to commence screen- crimes may be associated with substance
ing young clients. The exact age at which it is usea.
appropriate to commence regular screening Clients whose condition would be adversely
for substance use will vary depending on local affected by substance use.
prevalence and patterns of use. It is important Pregnant womenb.
to be aware of the legal age of consent in the
jurisdiction where the instrument will be used a
Examples of crimes associated with substance use include:
dealing, driving under the influence, violence while under the
and the legal requirements relating to screen- influence, stealing to fund substance use habits etc.
ing and intervention with adolescents who are b
While pregnant women are a high risk group, it is worth
under such age. noting that the ASSIST has not been formally validated in this
population as yet.
7 Problems related
to substance use
This chapter provides an overview of some of risk of complications of other health problems
the specific health and other problems due such as high blood pressure, diabetes and
to individual substances. The tables listing asthma. Children exposed to second-hand
the associated health risks are taken from the tobacco smoke are at increased risk of a range
ASSIST feedback report card (see Appendix C) of health problems such as respiratory
which is used to provide feedback to clients as infections, allergies and asthma. Pregnant
part of the brief intervention. It is important women who smoke are at higher risk of
for health workers administering the ASSIST miscarriage, premature labour and having a low
to have some knowledge of the health, birth weight baby. While the majority of people
social, legal and financial impacts of specific consume tobacco via smoking, use of tobacco
substances. This knowledge will be useful when products by means other than smoking, such
administering Q4 of the ASSIST around health, as chewing, or sniffing is also associated with
social, legal and financial problems, and also increased risk of diseases. Finally, exposure to
when delivering the brief intervention. second-hand tobacco smoke also increases the
risk of health problems among people who do
While the health risks associated with substance not smoke themselves.
use are the main focus here, it is worth noting
that substance use is also associated with a
range of social, legal and financial problems. The risks associated with use of
Some of the impacts that are pertinent to tobacco products include:
particular clients may not be specifically listed
Premature ageing and wrinkling of the skin
here. For example, the criminogenic impact that
substance use has caused for offenders within Low fitness and longer recovery times after
a prison population, or, the social and familial having a cold or flu
impacts that substance use may have caused Respiratory infections and asthma
for clients of family and child health services.
High blood pressure and diabetes mellitus
Health workers administering the ASSIST and
linked brief intervention should be aware of Miscarriage, premature labour and low birth
the impacts of substance use most relevant to weight babies for pregnant women
their clientele and include them in the ASSIST
Kidney disease
and linked brief intervention where relevant.
Chronic obstructive pulmonary diseases includ-
ing emphysema
Tobacco products
Heart disease, stroke and vascular diseases
Use of tobacco products is a major public
Cancers of lung, bladder, breast, mouth,
health problem and the leading cause of
throat and oesophagus
deaths attributable to psychoactive substance
use globally. Smoking of tobacco products is
a risk factor for a number of serious long term
health problems and increases the severity or
12 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
Cannabis Cocaine
Cannabis is the most widely consumed illicit Cocaine is a stimulant drug and its use is
drug globally. While it is possible to experience associated with a wide range of physical
cannabis overdose and toxicity, the likelihood and mental health problems. There is a
of death due to cannabis intoxication alone significant risk of toxic complications and
is very low, although combination with other sudden death, usually due to cocaines
drugs can result in overdose and death. effect on the cardiovascular system.
However, cannabis use is associated with Cocaine use is associated with risk
numerous negative health consequences. behaviour including high risk injecting and
Cannabis use in pregnancy has similar effects unsafe sex, putting users and their partners
on mother and baby to tobacco smoking and at significant risk of contracting a range of
can increase the severity and complications of sexually transmitted diseases and bloodborne
existing disease conditions such as high blood viruses. Cocaine effects have a rapid onset
pressure, heart disease, respiratory diseases and can wear off relatively quickly, which
and certain cancers. can result in a tendency towards multiple
use of the substance within a single session
by users of the drug. Cocaine also produces
The risks associated with use of strong craving, which can result from using
cannabis include: the drug even just a few times, and can lead
Problems with attention and motivation to severe cocaine dependence.
Decreased memory and problem solving ability The risks associated with use of
cocaine include:
High blood pressure
Difficulty sleeping, heart racing, headaches
Asthma and bronchitis and weight loss
Psychotic symptoms and psychoses particularly Numbness, tingling, clammy skin and skin
in those with a personal or family history of scratching or picking
schizophrenia
Intense craving and stress from the lifestyle
Heart disease and chronic obstructive pul-
monary disease Accidents and injury and financial problems
Cancers of the upper airway and throat Mood swings anxiety, depression and mania
Amphetamine-type Inhalants
stimulants (ATS)
Inhalants cover all volatile solvents that can
Amphetamine-type stimulants include be inhaled or breathed in, despite the fact
amphetamine, dexamphetamine, that the substances themselves may have a
methamphetamine and ecstasy (MDMA). range of different pharmacological actions.
This drug class, while having some The most commonly used volatile substances
similar effects to cocaine, has a different include petrol, solvents, glues, sprays, lacquers
pharmacological profile to cocaine, and use containing benzene and glues or paint thinners
can lead to a wide range of physical and containing toluene. Amyl nitrite and nitrous
mental health problems. There is growing oxide are also used in some communities. The
evidence that some ATS damage brain cells. most common way they are used is to sniff
Moreover, long term high dose amphetamine them from a container although some may
use is a risk factor for malnutrition which breathe them through a plastic bag.
may also cause permanent damage to brain
The short term effects include nausea, vomiting,
cells. There is also a high prevalence of social
headaches, and diarrhoea. Higher doses can
problems associated with regular ATS use
cause slurred speech, disorientation, confusion,
including relationship problems, financial
delusions, weakness, tremor, headaches, and
problems, work and study related problems.
visual hallucinations. Ultimately use can cause
Mood swings also are associated with regular
coma or death from a heart failure.
ATS use and some users report a worsening of
mental health problems such as depression In general, inhalants tend to be used by
and irritability over time. younger people for the purposes of experimen-
tation because of their ready availability, and
The risks associated with use of use may not continue over a long period of
amphetamine-type stimulants include: time. There are some groups however who will
use inhalants into adulthood, sometimes due
Difficulty sleeping, loss of appetite and weight loss,
to the lack of availability of other substances
dehydration and reduced resistance to infection
and cultural pressures. Inhalants tend not to
Jaw clenching, headaches and muscle pain have a high dependence liability which means
that users are less likely, compared to other
Mood swings anxiety, depression, agitation,
mania and panic substances, to become dependent on them.
However, inhalant use is associated with a
Tremors, irregular heartbeat and shortness of breath range of severe acute and chronic effects.
Difficulty concentrating and remembering things
The ASSIST can be administered on its own is a criminal offence, or at least illegal, in
or combined with other questions as part of most countries. There also is potential for
a general health interview, a lifestyle ques- stigmatisation and discrimination against
tionnaire, risk assessment or as a part of the those who are identified as substance users.
medical history. Any personal information collected from
clients must not be revealed to any individual
Clients are most likely to consent to screening or group of individuals without the clients
and give accurate answers to questions about direct consent. Confidentiality is assured by
substance use when the health worker: conducting the interview in a private place
shows that they are listening to the client; and by keeping the ASSIST results as part
of the confidential client record. Reassuring
is friendly and non-judgemental; clients that the information they give will be
shows sensitivity and empathy towards confidential will also help them to provide
the client; accurate information about their substance
use. However, many countries have limits
provides information about screening;
on what kind of information can be kept as
carefully explains the reasons for asking confidential. For example, many countries
about substance use; place an exclusion on confidentiality if a client
divulges that they are planning or doing harm
explains the limits of confidentiality to the client.
to themselves, someone else, or a child.
It may be helpful to explain that screening for
Health workers need to choose the best
substance use and related problems is similar
circumstances for administering the ASSIST
to other screening activities such as blood pres-
and be flexible and sensitive to client needs.
sure measurement, or asking about diet and
If clients are intoxicated, require emergency
exercise. Linking the screening to the present-
treatment or are distressed or in pain, it is
ing complaint where it is relevant, may help
best to wait until their medical condition has
clients to see the connection between their
stabilised and they are feeling comfortable
substance use and their health and make them
before administering the ASSIST. Use your clini-
more receptive to screening with the ASSIST.
cal judgement to determine the best time to
Protecting the privacy of clients and the discuss the ASSIST with each client.
confidentiality of the information that
clients provide is critical. This is especially
important when you are collecting
information relating to substance use.
The use of some psychoactive substances
20 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
10 The ASSIST
introduction
During the introduction the health worker While we are also interested in knowing about
should clarify which substances are to be your use of various illicit drugs, please be assured
that information on such use will be treated as
covered in the interview and ensure that they
strictly confidential.
are referred to by names which are familiar to
the client. The response card contains a list of
the substance categories covered by the ASSIST
For clients whose drug use is prohibited by
together with a range of names associated
law, culture or religion it may be necessary to
with each category (see Box 3). It also contains
acknowledge the prohibition and encourage
frequency responses for each question (see
honest responses about actual behaviour.
Box 4). The drug names on the card are those
For example, I understand that others may
which are most commonly used in the countries
think you should not use alcohol or other
in which the ASSIST was tested, but the
drugs at all but it is important in assessing your
health worker should use the most culturally
health to know what you actually do.
appropriate names for their location.
Currently the ASSIST is only validated for use
in an interview. Further research is needed to
determine if it is suitable for self administration.
However, the interview format has a number of
advantages and can be used even when clients
have low levels of literacy. The health worker
can explain questions which are poorly under-
stood and can ask probing questions to clarify
inconsistent or incomplete responses.
10 The ASSIST InTroduCTIon 21
j Other - specify:
There are certain practices that health care ing the questionnaire. If the clients responses
workers can do to ensure that the correct are not coded appropriately then the final
scores for clients are obtained and that the resultant score may be erroneous leading
client understands the questions that are asked to inappropriate feedback and a potentially
of them. Some of these are outlined in the inappropriate intervention. As shown in Box 4,
points below. questions 2 through 5 ask about the fre-
quency of events that have occurred in the last
Hold the questionnaire so the client cant see
3 months. It is worth noting that:
what you are writing, otherwise the clients
response may be influenced. The last 3 months = last 12 weeks
= last 90 days.
Every response for every drug and every
question must be circled including all zeros or Using Q2 as an example How often have you
negative responses, otherwise it may result in used the substances you mentioned in the last
incorrect scoring. 3 months?, the frequencies and their associ-
Remember you may need to rephrase some ated responses mean the following:
questions for some clients. Never means that the substance has not been
You may need to provide prompts for some used at all in the last 3 months (i.e. score = 0);
questions (e.g. Q4). Once or twice means that the substance
Build up a picture in your mind of the clients has been used a total of 1 to 2 times in the
substance use and potential problems related last 3 months (i.e. score = 2);
to their use as they answer each subsequent Monthly means the substance has been
question (especially Q2 regarding frequency used an average of 1 to 3 times per month in
of use in the last 3 months). Clients answers the last 3 months resulting in a total of 3 to
to questions that dont seem to be consistent 9 times over the last 3 months (i.e. score = 3);
with their frequency and pattern of drug use
should be queried further to ensure that you Weekly means the substance has been
have explained the question adequately and used an average of 1 to 4 times per week in
that client understands the question that is the last 3 months (i.e. score = 4);
being asked of them. Daily / Almost daily means the substance
has been used an average of 5 to 7 days per
It is extremely important for health work-
week in the last 3 months (i.e. score = 6).
ers to understand the scoring of the ASSIST
responses to questions before first administer-
11 good PrACTICe In ASSIST queSTIonnAIre AdMInISTr ATIon 23
1 Q2. Someone who had used heroin twice in the last three months
would be coded as ?
2 Q2. Someone who drank alcohol every day of the week except
Mondays in the last 3 months would be coded as ?
12 How to administer
the ASSIST questionnaire
The ASSIST questionnaire already contains Questions 1 and 2 are filter questions which
some prompts and instructions to guide means they determine which substances should
interviewers during the interview. Some of be asked about in subsequent questions.
these instructions enable the interviewer to
leave out some questions for some clients and A general flow chart of how to administer the
so shorten the interview. Others remind the ASSIST is shown below in Figure 1.
interviewer to probe for more detail to obtain
accurate responses. While some flexibility is
possible when asking the questions, it is impor-
tant to make sure that all the relevant ques-
tions have been asked and that the answers
have been recorded.
If yes to
any substance
If never to All
Q2 Q6*, Q7* & Q8
If yes to
any substance
Q3, Q4 & Q5
Q1 In your life which of the following use the same terminology for substances as
substances have you ever used the client throughout the interview;
(non-medical use only)?
give examples of other drugs e.g. GHB,
(Responses = yes or no) kava, datura and khat;
Q1 asks about lifetime use of substances, i.e., record other drug in the space provided;
those substances the client has ever used, if a substance has never been used, dont ask
even if it is only once. It is a good way to start about it again within the context of the inter-
talking to a client about their substance use view (all responses for this drug will be no);
without being too intrusive, and also gives you
a brief history of the clients substance use. remember Q1 is not included in scoring.
Every client should be asked this question for
all the substances listed. Q2 In the past 3 months how often have
you used the substances you mentioned?
Q1 is a filter question, which means the
answers recorded determine what happens (Responses = never, once or twice,
next with regards to asking clients about monthly, weekly, daily/almost daily)
specific drugs in the following questions. If
If the client answers yes to Q1 for any of the
the client answers no to every substance in
substances listed, then move on to Q2 which
Q1 the health worker should ask a probing
asks about substance use in the previous three
question Not even when you were in
months. Q2 should be asked only for each of
school? If the response is still no to all the
the substances ever used (as recorded in Q1).
substances, then the interview is terminated.
Q2 also is a filter question, which means
If the client answers no to certain substances
the answers recorded determine what hap-
only (for example, inhalants), the health care
pens next with regards to asking clients about
worker does not ask about that substance
specific drugs in the questions 3, 4 and 5. If the
(i.e., inhalants) again in the ASSIST interview.
response is never to all of the items in Q2,
Points to remember when asking Q1 include: that is, no substances have been used by the
client in the last 3 months, then move on to Q6
as you are going through each substance
which asks about substance use across the cli-
group, remind the client of what that
ents lifetime. If any substances have been used
substance category includes (for example,
in the past three months then continue with
amphetamine-type stimulants includes
questions 3, 4 and 5 for each substance used.
amphetamines, meth, speed and ecstasy)
and also of any local terms for the
substance including slang terms;
circle no or yes for each substance;
26 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
Points to remember when asking Q2 include: then they may experience a strong desire
or urge to use it. This is sometimes referred
Ask only about the substances that client has
to as craving or hanging out by clients who
reported ever using (according to Q1).
are already dependent. It is worth noting that
Circle all responses, including the 0 this question does not aim to record a
responses even for drugs not used ever, mild or transient desire to use, or even
or not used in the last 3 months. necessarily a desire to use that is associated
with opportunity (for example, a client who
May need to remind client again of drug
gets offered a drug and experiences a desire to
terms and street names.
use as a result, but did not have a desire to use
Remember coding definitions for the last before that happened). Not all clients who use
3 months (i.e. never, once or twice, substances will experience a strong desire to use.
monthly, weekly, daily/almost daily).
Scoring high on Q3 is generally consistent with:
The client may not answer using the above
terminology (i.e. never, once or twice, more frequent use of the substance (usually
monthly, weekly, daily/almost daily) and once a week or more), and / or;
you may need to calculate the appropriate previous problems with the substance, and / or;
frequency of use from the information they
have given you (for example, a client who the type of substance used (desire to use is
tells you that they have been smoking mari- closely related to the abuse and dependence
juana once every two weeks, you would need liability of a substance, and for example,
to re-interpret and score as monthly). cocaine can produce a strong desire to use
even only after a few uses, whereas, almost
All the substances that have been used in the daily alcohol use may not produce a strong
last 3 months should now be asked about in desire to use in absence of alcohol depend-
questions 3, 4 and 5. ence), and / or;
injecting drugs.
Q3 During the past 3 months how often
have you had a strong desire or urge to The above are general pointers for helping
use (drug)? to determine how to score a client on Q3,
however, it is important to use your clinical
(Responses = never, once or twice,
judgment too, as some clients may have
monthly, weekly, daily/almost daily)
different experiences.
Q3 reflects high risk use or dependence on
a substance. When a client starts to use a
substance with increasing frequency, or they
have had past problems with the substance,
12 hoW To AdMInISTer The ASSIST queSTIonnAIre 27
Other points to remember when asking Q3 include: lems, and it is up to the health care worker to
help the client link these two things together.
Ask only about the substances that client has
This may be the first time that a client actually
reported using in last 3 months (according
recognises and verbalises the direct impacts
to Q2). Some clients may be experiencing
that their substance use is having on them,
a strong desire or urge to use but have not
with the help of the health worker. Accordingly,
used the substance in the last 3 months but
it is worth prompting the client with examples
this would not be recorded by the ASSIST.
of what is meant by health, social, legal and
For example, someone who stopped smoking
financial problems. A lack of prompting or
cigarettes 5 months ago, but still experiences
explanation around this question could lead to
a strong desire to use cigarettes would not
lower scoring on this question and an overall
be recorded on Q3 because they have not
erroneous score on the ASSIST. More informa-
smoked cigarettes in the last 3 months.
tion about specific substance use problems can
To assist clients to understand the question, be found on the ASSIST feedback report card
daily use of a substance could be used to set or in Chapter 8 of this manual. It is important
a benchmark for desire to use that substance. that health workers be aware of the most com-
For example, someone who smokes cigarettes mon problems associated with use of specific
everyday is very likely to be experiencing a substances and mentions these as examples to
strong daily desire to smoke cigarettes. The prompt clients.
question could then be asked of the client,
You know the level of desire you experience For example, for tobacco using clients you
for cigarettes, how often in the last 3 months might say, During the past 3 months how
would you have experienced a similar level of often has your use of cigarettes led to any
craving for alcohol, marijuana etc ?. health, social, legal or financial problems such
as breathlessness, finding yourself less fit than
usual, taking longer to recover from infections
Q4 During the past 3 months how often
or financial problems because you dont have
has your use of (drug) led to health, social,
enough money to purchase what you need
legal or financial problems?
after buying cigarettes ?.
(Responses = never, once or twice,
For alcohol using clients you might say, During
monthly, weekly, daily/almost daily)
the past 3 months how often has your use of
Q4 on the ASSIST aims to determine if a cli- alcohol led to any health, social, legal or finan-
ents substance use is creating any problems cial problems such as bad hangovers, vomiting,
for them, and the frequency with which this stomach pain, sleeping poorly, getting into argu-
has been happening in the last 3 months. Q4 ments with people, drink driving, doing things
is only asked around substances used in the while you are drunk that you later regret ?.
last 3 months (as identified in Q2). Many clients
may not be aware of problems associated with
their substance use, particularly health prob-
28 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
For cannabis using clients you might say, Q5 During the past 3 months how often
During the past 3 months how often has your have you failed to do what was normally
use of marijuana led to any health, social, legal expected of you because of your use of
or financial problems such as forgetting to do (drug)?
things, difficulty paying attention or getting
(Responses = never, once or twice,
motivated, problems getting organised, feeling
monthly, weekly, daily/almost daily)
depressed or anxious ?.
Q5 is only asked for substances that have been
For clients using amphetamine-type
used in the last 3 months (as identified by Q2).
stimulants you might say, During the
This question is designed to find out if the
past 3 months how often has your use of
client is experiencing problems fulfilling their
amphetamines led to any health, social, legal
usual role obligations because of their substance
or financial problems such as having a bad
use, which usually results in repercussions or
come-down and feeling depressed, anxious
consequences for the client. A failure to fulfil
and irritable the day or so after you have used,
usual role obligations may result from being
feeling angry, aggressive or uptight, getting
intoxicated by the substance, recovering from
headaches, sleeping poorly, dental problems
using the substance or spending all available
from grinding your teeth ?.
time seeking the substance out (for example,
Some of the common problems that are par- waiting hours for a dealer and missing appoint-
ticularly pertinent to the clients of your agency ments or events that the client was expected
or organisation may not be specifically listed to attend). You may need to prompt the client
above. For example, the criminogenic impacts with examples of failed role obligations.
that substance use may have caused for
Common examples of role obligations that
offenders within a prison population, or, the
may not be fulfilled as a result of substance
social and familial impacts that substance use
use include:
may have caused for clients of family and child
health services. Health workers administering missing work and losing pay or getting in
the ASSIST and linked brief intervention should trouble with the employer, having problems
be aware of the common problems associated keeping up with work, poor work perform-
with the substance use of their clientele and ance, negligence, losing job;
include them as examples when administering
missing school, college or university and
Q4 of the ASSIST.
falling behind, failing or doing poorly in
assessments, or suspension or expulsion;
failing to maintain usual family or relationship
commitments, neglecting child caring activi-
ties, neglecting house cleaning or paying of
bills, difficulty maintaining relationships with
partner/friends/family or missing important
family events.
12 hoW To AdMInISTer The ASSIST queSTIonnAIre 29
Tobacco is excluded from Q5 because, in You will need to turn the questionnaire back
general, people dont fail their role obligations to the front page to see what substances have
because they are smokers. been used in clients life. At first doing this may
seem cumbersome and awkward, however,
It is worth noting that some people who are most health workers get used to doing this
severely dependent on a substance may not after administering the ASSIST a few times.
have any usual role obligations because they
have lost their job/family/home/support etc. Recently expressed concern to the clients
some time ago because of their heavy and substance use in the last 3 months attracts
continued substance use. In such cases, rather a higher score than concern to the clients
than score these people as never, basic tasks behaviour over 3 months ago. Even concern
such as house cleaning, feeding themselves, expressed years ago needs to be recorded in the
keeping appointments with doctors, welfare yes, but not in the past 3 months category.
agencies etc. should be used as prompts. Such
clients could be asked a re-phrased version of Concern can include things such as discussion,
the question such as, If you had responsibili- questioning, nagging, advice, worry, anger etc.
ties and obligations, such as going to work or by the other party to the client.
looking after your family, would you be able to
fulfil them? Q7 Have you ever tried to cut down or
stop using (drug) but failed?
Q6 Has a friend or relative or anyone else (Responses = no, never, yes, in the
ever expressed concern about your use of
past 3 months, yes, but not in the past
(drug)?
3 months)
(Responses = no, never, yes, in the
Q7 is an indicator of dependence or high risk
past 3 months, yes, but not in the past
use and is designed to find out about loss
3 months)
of control over substance use in the clients
This question is designed to find out if another lifetime. Substance dependence, or addiction, is
person (e.g. family, friend, partner, spouse, a chronic relapsing disorder, and many people
parents, children, doctor, employer, teacher need to make several attempts to cut down
etc.) has expressed concern about the clients or stop use before they are actually successful.
substance use. This question investigates serious attempts
to cut down or stop, rather than just passing
thoughts of cutting down or half-hearted
All substances that were recorded when asked
Q1 on lifetime use must be asked about in this efforts. Usually clients scoring positive on this
question not just those substances used in the question will have been using the substance
last 3 months. reasonably frequently generally in the order
of once a week or more, and/or at high
concentrations (such as a heavy binge session
on alcohol).
30 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
A loss of control is reflected by failed attempts to You will need to turn the questionnaire back
control, cut down or stop using the substance. to the front page to see what substances have
For this question unsuccessful attempts to cut been used in clients life.
down in the last 3 months attract the highest
score for this question and a current problem Clients can score 0 (no, never) on this
with their substance use. question for 3 reasons:
not necessary to cut down i.e. Dont
Clients whose last unsuccessful attempt to cut
use enough;
down was more than 3 months ago attract a
lesser score, and indicate that the client has happy users (pre-contemplators) i.e. Dont
had a past problem with their substance use. want to cut down;
These clients are at a greater risk of returning to
have successfully cut down the first time they
problematic or dependent substance use than
tried.
novice users who dont have past problems.
Even failed attempts to control substance use Finally, because this question contains multiple
that occurred years ago need to be recorded as concepts, health workers may find it helpful
yes, but not in the past 3 months category. to break this question down into 3 parts. For
example:
It is worth noting that successful attempts
to cut down are not recorded. If a client has Have you ever tried to cut down on smoking
made several attempts to cut down and was cigarettes? (yes or no)
successful eventually, the health worker needs Were you successful? (yes or no)
to record the last unsuccessful attempt. For
example, someone that successfully stopped When was the last time you tried and
smoking cigarettes 3 months ago, but had werent successful? (never or yes in the
several failed attempts prior to that would be past 3 months or yes, but not in the past 3
recorded as yes, but not in the last 3 months. months)
Q8 Have you ever used any drug by Drugs most commonly injected are opioids,
injection? amphetamine-type stimulants, cocaine and
sedatives such as benzodiazepines. Injection
(Responses = no, never, yes, in the
patterns for opioids are sometimes different
past 3 months, yes, but not in the past
to those for amphetamine-type stimulants and
3 months)
cocaine. While people who inject opioids tend
This question is a possible indicator of to do it with some regularity, people injecting
dependence or high risk use and is designed stimulants tend to cluster their injecting, or do
to find out about the recency of injecting it in runs. That is, they may inject a few days
substance use in the clients lifetime. Clients in a row and then have a break for a few days,
who move to injecting use are more likely to weeks or even months before their next ses-
be or become dependent on the substance, sion of injecting.
depending on the frequency of use. Injecting
As a general rule, clients injecting an
is also associated with an additional range
average of more than 4 times per month
of harms including both fatal and non-fatal
over the last 3 months may require referral
overdose (particularly with opioids), and
to specialist treatment.
also the risk of psychosis (particularly with
amphetamine-type stimulants). Infections
with bloodborne viruses are also associated
with injecting.
13 Scoring of the
ASSIST questionnaire
Each question on the ASSIST has a set of For the purposes of practicality and ease, this
responses to choose from, and each response is referred to as the ASSIST risk score for (drug)
from questions 2 to 7 has a numerical score. in these manuals. As laid out in the ASSIST
The interviewer circles the numerical score questionnaire, each client will have 10 risk
that corresponds to the clients response for scores. That is:
each question. At the end of the interview
a ASSIST risk score for tobacco (range 0 31)
the scores from questions 2 through to 7
are added together across each individual b ASSIST risk score for alcohol (range 0 39)
substance (tobacco, alcohol, cannabis, cocaine, c ASSIST risk score for cannabis (range 0 39)
amphetamine-type stimulants, inhalants, d ASSIST risk score for cocaine (range 0 39)
sedatives/sleeping pills, hallucinogens, opioids
e ASSIST risk score for amphetamine-type
and other drugs) to produce an ASSIST risk
stimulants (range 0 39)
score for each substance (See Box 5 for an
example). In technical reports and papers this f ASSIST risk score for inhalants (range 0 39)
score is referred to as the specific substance g ASSIST risk score for sedatives or sleeping pills
Involvement score for each drug class. (range 0 39)
hASSIST risk score for hallucinogens
BOx 5 | Example of calculating an (range 0 39)
ASSIST risk score for cannabis* i ASSIST risk score for opioids (range 0 39)
A client has given the following answers on the j ASSIST risk score for other drugs
ASSIST for cannabis
(range 0 39).
Q2c Weekly Score = 4
Q3c Once/twice Score = 3
This score can be recorded on the last page of
the ASSIST questionnaire and the questionnaire
Q4c Monthly Score = 5
kept in the clients record if appropriate. The
Q5c Once/twice Score = 5 client does not see the ASSIST questionnaire
Q6c Yes, but not in past 3 months Score = 3 but rather the ASSIST feedback report card
Q7c No, Never Score = 0 which has the scores recorded for the client in
an appropriate way to provide feedback as part
ASSIST risk score for cannabis Total = 20
of the brief intervention.
*
Similar scores are calculated for all other substances used in
the past 3 months with the exception of tobacco which does not
include Q5 in the calculation.
13 SCorIng of The ASSIST queSTIonnAIre 33
14 Interpretation of
ASSIST scores
Screening activities such as blood pressure It may be helpful to appoint one member of
measurement, pap smears, cholesterol staff as the ASSIST coordinator. This person
measurement, monitoring of childrens height can be responsible for making sure that all staff
and weight and general health and welfare understand their roles and responsibilities and
enquiries are some of the existing screening that all of the necessary tasks are carried out.
practices occurring in many primary health
care settings. Screening for problems related to The plan should be clear and address all of
substance use and appropriate client care has the issues involved in implementing an ASSIST
also been widely recognised as an important screening programme in a particular practice.
part of good primary health care practice22, 23. Some of the questions which need to be
addressed are listed in the Box 7.
Implementing a screening and brief
intervention programme in your agency
BOx 7 | Implementation questions
requires a commitment from management and
staff and involves four main aspects: Which clients will be screened?
planning What is the prevalence and type of substance
used in this setting?
training
How will clients needing screening be identified?
monitoring
How often will clients be screened?
feedback.
Who will administer the ASSIST and
brief intervention?
Planning When during the clients visit will the ASSIST
be administered?
Planning is needed to design the screening
What follow-up actions will be taken?
programme and make sure that the processes
fit into the special circumstances of each How will records of screening and follow-up
primary care practice. Ideally all staff of the actions be kept?
primary health care practice should be involved How will copies of the ASSIST and information
in planning for the programme. Staff who materials be obtained, stored and managed?
are involved in planning are more likely to How will follow-up be scheduled?
understand the reasons for the programme,
How will you inform clients of the ASSIST
feel a sense of ownership and enthusiasm for
screening programme?
its implementation, understand their roles in
the programme and be committed to making Which staff will be involved in the pro-
gramme? What will be their roles?
it work. Staff from different backgrounds and
with different roles and experience will be What resources and processes do you have in
the practice which will help you manage the
able to work together to identify any possible
screening programme?
difficulties and create ways to overcome them.
38 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
The plan should be comprehensive and Including health summary sheets in the client
ensure that screening is timely, systematic record to provide a summary of:
and efficient but should also be flexible so
particular health needs;
that health workers can make the most of
unexpected opportunities for screening with whether the client has been screened
the ASSIST. The plan that is developed also using the ASSIST;
needs to consider the prevalence and type
their ASSIST scores and risk status;
of substance use relevant to the location and
clientele of the primary health care setting. what interventions have been undertaken;
For example, in a setting where injecting drug when they are next due to be screened.
use may be prevalent then ready access to STD
testing and information on less risky injecting Placing stickers on the client record to indi-
practices should be available. Settings in cate at a glance whether clients have been
which amphetamine-type stimulant use is screened and when screening took place.
common should consider having information Implementing reminder systems. Reminders
on common mental health problems related to can be used to:
ATS use and access to mental health services.
invite clients to take part in the
There is strong evidence for the effectiveness screening programme;
of a number of strategies for implementing
prompt the health worker to administer
prevention and screening programmes in
the ASSIST during the client visit;
primary care. These strategies include:
invite the client for follow-up if
Using the waiting room to cue clients to think
needed (recall);
about their substance use by providing:
remind health workers and clients when
posters and displays about substance
repeated screening is due.
related risks and problems;
a well organised notice board containing If the resources are available, computerised
information about the programme; information systems can be of great assistance
in managing a screening programme.
practice newsletters;
relevant information leaflets and client
education material.
16 hoW To InClude SCreenIng WITh The ASSIST In every dAy Pr ACTICe 39
*
Some training manuals and materials in languages other than
English are available on the WHO ASSIST website, http://www.who.
int/substance_abuse/activities/assist/en/
40 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
17 Guide to
appendices
The attached appendices contain materials for Clients who are high risk injectors (injecting four
both health workers and clients. These can be times per month or more in the last 3 months)
photocopied and used freely where necessary, may also find this card helpful, but will require
in accordance with the instructions outlined in more intensive treatment.
this manual.
Appendix E
Appendix A Translation and adaptation to local
The Alcohol, Smoking and Substance languages and culture: a resource for
Involvement Screening Test (ASSIST v3.1) clinicians and researchers
The ASSIST questionnaire can be photocopied This resource sets out the guidelines by which
for repeated use in primary care and other the ASSIST and related materials must be
treatment settings. translated. There are some versions of the
ASSIST available on the website (http://www.
Appendix B who.int/substance_abuse/activities/assist/en/)
in languages other than English. Please contact
ASSIST v3.1 response card for clients
the WHO for support and registration if you are
This is a one page document which should be planning to translate the ASSIST materials or
given to clients when administering the ASSIST resources into your language:
in order to aid responding. The response card
can be photocopied.
Management of Substance Abuse,
Appendix C Department of Mental Health and
Substance Abuse
ASSIST v3.1 feedback report card for clients
World Health Organization
The ASSIST feedback report card should be 20 Avenue Appia
completed by the health worker with the results 1211 Geneva 27, Switzerland
of the ASSIST and used to give feedback and
advice to the client around their substance Telephone: +41 22 791 3494
use. The client should be encouraged to take Fax: +41 22 791 4851
the card home with them. In the front you can E-mail: msb@who.int
find the ASSIST scores for each substance and Website: www.who.int/substance_abuse/
risk levels followed by specific health and other activities/assist/en/
problems associated with substance use. Health
workers should use the ASSIST feedback report
card in conjunction with a brief intervention. Appendix F
Answers to self-testing questions from
Appendix D Chapter 11 on Good Practice in ASSIST ques-
ASSIST risks of injecting card for clients tionnaire administration.
AppendixA
The Alcohol, Smoking and Substance Involvement
Screening Test (ASSIST v3.1)
QuESTION 1 | In your life, which of the following substances have you ever used
(non-medical use only)?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc.) No Yes
*
ASSIST V3.1 is to be utilized by for screening in clinical settings. For research purposes please use the previous version ASSIST V3.0.
World Health Organization 2010
APPendIx A The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST (ASSIST v3.1) 43
almost daily
have you used the substances you mentioned (first
Monthly
Once or
Daily or
Weekly
drug, second drug, etc)?
Never
twice
a Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 2 3 4 6
j Other specify: 0 2 3 4 6
Daily or
Weekly
twice
j Other specify: 0 3 4 5 6
44 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
Almost Daily
often has your use of (first drug, second drug, etc) led
Monthly
Once or
Daily or
Weekly
to health, social, legal or financial problems?
Never
Twice
a Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 4 5 6 7
j Other specify: 0 4 5 6 7
Almost Daily
often have you failed to do what was normally
Monthly
Once or
Daily or
Weekly
expected of you because of your use of (first drug,
Never
Twice
j Other specify: 0 4 5 6 7
Ask questions 6 & 7 for all substances ever used (i.e. those endorsed in Q1).
APPendIx A The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST (ASSIST v3.1) 45
No, never
3 months
a Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 6 3
j Other specify: 0 6 3
Ask questions 6 & 7 for all substances ever used (i.e. those endorsed in Q1).
past 3 months
No, never
3 months
j Other specify: 0 6 3
Ask questions 6 & 7 for all substances ever used (i.e. those endorsed in Q1).
46 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
3 months
(Please tick the appropriate box)
IMPORTANT NOTE
Clients who have injected drugs in the last 3 months should be asked about their pattern of injecting during
this period, to determine their risk levels and the best course of intervention.
More than 4 days per month, on Further assessment and more intensive
average, over the last 3 months treatment
Note that Q5 for tobacco is not coded, and is calculated as: Q2a + Q3a + Q4a + Q6a + Q7a.
The type of intervention is determined by the patients specific substance involvement score
b Alcohol 0 10 11 26 27+
c Cannabis 03 4 26 27+
d Cocaine 03 4 26 27+
e ATS 03 4 26 27+
f Inhalants 03 4 26 27+
g Sedatives 03 4 26 27+
h Hallucinogens 03 4 26 27+
i Opioids 03 4 26 27+
Now use ASSIST feedback report card to give client brief intervention.
48 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
AppendixB
ASSIST v3.1 response card
j Other specify:
AppendixC
ASSIST v3.1 feedback report card
0 10 Lower
b Alcoholic beverages 11 26 Moderate
27+ High
03 Lower
c Cannabis 4 26 Moderate
27+ High
03 Lower
d Cocaine 4 26 Moderate
27+ High
03 Lower
e Amphetamine-type stimulants 4 26 Moderate
27+ High
03 Lower
f Inhalants 4 26 Moderate
27+ High
03 Lower
g Sedatives or sleeping pills 4 26 Moderate
27+ High
03 Lower
h Hallucinogens 4 26 Moderate
27+ High
03 Lower
i Opioids 4 26 Moderate
27+ High
03 Lower
j Other specify: 4 26 Moderate
27+ High
Lower: You are at lower risk of health and other problems from your current pattern of use.
Moderate: You are at moderate risk of health and other problems from your current pattern of
substance use.
High: You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as
a result of your current pattern of use and are likely to be dependent.
50 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
A | Tobacco B | Alcohol
Your risk of experiencing these harms is (tick one): Your risk of experiencing these harms is (tick one):
Regular tobacco smoking is associated with: Regular exessive alcohol use is associated with:
Premature ageing and wrinkling of the skin Hangovers, aggressive and violent behaviour,
accidents and injury, nausea and vomiting
Low fitness and longer recovery times after
having a cold or flu Reduced sexual performance and
premature ageing
Respiratory infections and asthma
Digestive problems, ulcers, inflammation of
High blood pressure and diabetes mellitus the pancreas and high blood pressure
Miscarriage, premature labour and low birth Anxiety and depression, relationship difficulties,
weight babies for pregnant women and financial and work problems
Kidney disease Difficulty remembering things and
solving problems
Chronic obstructive pulmonary diseases
including emphysema Birth defects and brain damage in babies of
pregnant women
Heart disease, stroke and vascular diseases
Permanent brain damage leading to memory
Cancers of lung, bladder, breast, mouth,
loss, cognitive deficits and disorientation
throat and oesophagus
Stroke, muscle and nerve damage
Suicide
APPendIx C ASSIST v3.1 feedbACk rePorT CArd 51
Cancers of the upper airway and throat Permanent damage to brain cells
Intense craving and stress from the lifestyle Dizziness and hallucinations, nausea, drowsi-
ness, disorientation and blurred vision
Accidents and injury and financial problems
Headaches, accidents and injury, unpredictable
Mood swings anxiety, depression and mania and dangerous behaviour
Coordination difficulties, slowed reactions and
Paranoia, irrational thoughts and difficulty poor oxygen supply to the body
remembering things
Memory loss, confusion, depression, aggression
Aggressive and violent behaviour and extreme tiredness
Psychosis after repeated use of high doses Delirium, seizures, coma and organ damage
(heart, lungs, liver, kidneys)
Sudden death from cardiovascular acute
Death from heart failure
conditions
52 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
Regular use of sedatives is associated with: Regular use of opioids is associated with:
Difficulty concentrating and remembering things Drowsiness, constipation, tooth decay and
irregular menstrual periods
Nausea, headaches and unsteady gait
Difficulty concentrating and remembering things
Sleeping problems
Depression, reduced libido and impotence
Anxiety and depression
Financial difficulties and criminal offences
Tolerance and dependence after a short
period of use Relationship stress
Overdose and death if used with alcohol, Tolerance, dependence and withdrawal symptoms
opioids or other depressant drugs
Overdose and death from respiratory failure
H | Hallucinogens
Your risk of experiencing these harms is (tick one):
Difficulty sleeping
Mood swings
Flash-backs
AppendixD
ASSIST risks of injecting card Information for clients
If you inject heroin or other sedatives you clean the injecting site
are more likely to overdose. use a different injecting site each time
The injecting behaviour: inject slowly
If you inject you may damage your skin put your used needle and syringe in a hard
and veins and get infections. container and dispose of it safely.
You may cause scars, bruises, swelling, If you use stimulant drugs like amphetamines
abscesses and ulcers. or cocaine the following tips will help you
Your veins might collapse. reduce your risk of psychosis:
If you inject into the neck you can cause avoid injecting and smoking
a stroke.
avoid using on a daily basis.
Sharing of injecting equipment:
If you use depressant drugs like heroin the
If you share injecting equipment (needles & following tips will help you reduce your risk
syringes, spoons, filters, etc.) you are more of overdose:
likely to spread bloodborne virus infections
avoid using other drugs, especially seda-
like hepatitis B and C and HIV.
tives or alcohol, on the same day
use a small amount and always have a trial
taste of a new batch
have someone with you when you are using
avoid injecting in places where no-one can
get to you if you do overdose
know the telephone numbers of the
ambulance service.
54 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
AppendixE
Translation and adaptation to local languages and culture:
a resource for clinicians and researchers
The ASSIST instrument, instructions, drug Translation of this manual and companion
cards, response scales and resource manuals documents may also be undertaken if
may need to be translated into local languages required. These do not need to undergo the
for use in particular countries or regions. full procedure described above, but should
Translation from English should be as direct as include an expert bilingual panel.
possible to maintain the integrity of the tools
and documents. However, in some cultural Before attempting to translate the ASSIST
settings and linguistic groups, aspects of the and related documents into other languages,
ASSIST and its companion documents may interested individuals should consult with the
not be able to be translated literally and there WHO about the procedures to be followed
may be socio-cultural factors that will need to and the availability of other translations.
be taken into account in addition to seman- Contact WHO at:
tic meaning. In particular, substance names
may require adaptation to conform to local Management of Substance Abuse,
conditions, and it is also worth noting that the Department of Mental Health and
definition of a standard drink may vary from Substance Abuse
country to country. World Health Organization
20 Avenue Appia
Translation should be undertaken by a bilingual
1211 Geneva 27, Switzerland
translator, preferably a health professional
with experience in interviewing. For the Telephone: +41 22 791 3494
ASSIST instrument itself, translations should be Fax: +41 22 791 4851
reviewed by a bilingual expert panel to ensure E-mail: msb@who.int
that the instrument is not ambiguous. Back Website: www.who.int/substance_abuse/
translation into English should then be carried activities/assist/en/
out by another independent translator whose
main language is English to ensure that no
meaning has been lost in the translation. This
strict translation procedure is critical for the
ASSIST instrument to ensure that comparable
information is obtained wherever the ASSIST is
used across the world.
APPendIx f AnSWerS To Self-TeSTIng queSTIonS froM ChAPTer 11 55
AppendixF
Answers to self-testing questions from Chapter 11
SELF-TESTINg | Answers
1 Q2. Someone who had used heroin twice in the last three months Once or twice = 2
would be coded as ?
2 Q2. Someone who drank alcohol every day of the week except Daily/almost daily = 6
Mondays in the last 3 months would be coded as ?
3 Q2. Someone who smoked marijuana 3 to 4 times per week in the Weekly = 4
last 3 months would be coded as ?
5 Q2. Someone who smoked cigarettes everyday but has been Weekly = 4
abstinent for the last 6 weeks would be coded as ?
AppendixG
Two client scripts (Chloe and Dave)
The person who is administering the ASSIST questionnaire (interviewer) uses a blank ASSIST ques-
tionnaire to record the clients responses. The ASSIST introduction, which is provided on the front
page of the ASSIST questionnaire, should also read or paraphrased as part of the role-play, and the
ASSIST response card given to the client.
The person who is playing the client reads this script in response to interviewers questions.
The script must be read as written, as any changes may result in erroneous coding and
scoring by interviewer.
Following administration of the ASSIST questionnaire, the interviewer should calculate the clients
final scores and record them in the box on the last page of the ASSIST v3.1 questionnaire. The
scores calculated by the interviewer should be compared with the correct scores provided on the
back page of this script. If there are any differences, they should be discussed and resolved by the
role-play pair, so that the final scores obtained by the interviewer reflect the scores provided on
this script.
Some of your responses have brackets around them (e.g. Q2d.). This means that the interviewer
should not have asked you this question due to filtering out. The answer written in brackets may
still be provided to the interviewer, along with feedback to remind them that they did not need
to ask you this question.
APPendIx g T Wo ClIenT SCrIPTS ( Chloe And dAve ) 57
QuESTION 1 | In your life, which of the following substances have you ever used
(non-medical use only)?
j Other specify: No
QuESTION 2 | In the past three months, how often have you used the substances you
mentioned (first drug, second drug, etc)?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Every day
f Inhalants (nitrous, glue, petrol, paint thinner, etc.) Ive used nitrous oxide twice
g Sedatives or sleeping pills (diazepam, alprazolam, Havent used them in the last 3 months
flunitrazepam, midazolam, etc.)
h Hallucinogens (LSD, acid, mushrooms, trips, ketamine, etc.) (Never tried hallucinogens)
QuESTION 3 | During the past three months, how often have you had a strong desire
or urge to use (first drug, second drug, etc)?
b Alcoholic beverages (beer, wine, spirits, etc.) Ive had some desire to drink but I
wouldnt say a strong desire so I would
have to say never in the last 3 months
e Amphetamine-type stimulants (speed, meth, ecstasy, etc.) Probably have had a really strong crav-
ing for speed once or twice in the last
3 months
g Sedatives or sleeping pills (diazepam, alprazolam, (Havent used them in last 3 months)
flunitrazepam, midazolam, etc.)
h Hallucinogens (LSD, acid, mushrooms, trips, ketamine, etc.) (Never tried hallucinogens)
QuESTION 4 | During the past three months, how often has your use of
(first drug, second drug, etc) led to health, social, legal or financial problems?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Once or twice in the last 3 months
Ive noticed that I have been really out
of breath after exercise and I think its
because of smoking
b Alcoholic beverages (beer, wine, spirits, etc.) Ive had really bad hangovers on average
about once every fortnight in the last
3 months
e Amphetamine-type stimulants (speed, meth, ecstasy, etc.) Ive run out of money twice in the last
three months because of buying speed and
Ive had some problems paying my bills
g Sedatives or sleeping pills (diazepam, alprazolam, (Havent used them in last 3 months)
flunitrazepam, midazolam, etc.)
h Hallucinogens (LSD, acid, mushrooms, trips, ketamine, etc.) (Never tried hallucinogens)
QuESTION 5 | During the past three months, how often have you failed to do what was
normally expected of you because of your use of (first drug, second drug, etc)?
a Tobacco products
g Sedatives or sleeping pills (diazepam, alprazolam, (Havent used them in last 3 months)
flunitrazepam, midazolam, etc.)
h Hallucinogens (LSD, acid, mushrooms, trips, ketamine, etc.) (Never tried hallucinogens)
QuESTION 6 | Has a friend or relative or anyone else ever expressed concern about
your use of (first drug, second drug, etc)?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Yes, my doctor said I should stop smok-
ing about a year ago, but not since then
h Hallucinogens (LSD, acid, mushrooms, trips, ketamine, etc.) (Never tried hallucinogens)
QuESTION 7 | Have you ever tried to cut down on using (first drug, second drug, etc)
but failed?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Yes, Ive tried in the last 3 months but I
havent been successful
g Sedatives or sleeping pills (diazepam, alprazolam, I used to use a lot of Valium and had to cut
flunitrazepam, midazolam, etc.) down on it but I was successful the first time
h Hallucinogens (LSD, acid, mushrooms, trips, ketamine, etc.) (Never tried hallucinogens)
The type of intervention is determined by the patients specific substance involvement score
b Alcohol 14 0 10 11 26 27+
c Cannabis 2 03 4 26 27+
d Cocaine 0 03 4 26 27+
e ATS 17 03 4 26 27+
f Inhalants 2 03 4 26 27+
g Sedatives 3 03 4 26 27+
h Hallucinogens 0 03 4 26 27+
i Opioids 0 03 4 26 27+
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Total
IMPORTANT NOTE
Y/N 3m means; Yes, but not in the past 3 months (score of 3).
O-T means; Once or Twice.
Y 3m means; Yes, in the past 3 months (score of 6).
Q1 and Q8 are not included in the scoring.
62 ASSIST The AlCohol, SMokIng And SubSTAnCe InvolveMenT SCreenIng TeST
QuESTION 2 | In the past three months, how often have you used the substances you
mentioned (first drug, second drug, etc)?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Every day
c Cannabis (marijuana, pot, grass, hash, etc.) Pretty much every day
e Amphetamine-type stimulants (speed, meth, ecstasy, etc.) Not in the last 3 months
f Inhalants (nitrous, glue, petrol, paint thinner, etc.) (Never tried inhalants)
h Hallucinogens (LSD, acid, mushrooms, trips, Ive had a couple trips in the last
ketamine, etc.) 3 months (twice)
i Opioids (heroin, morphine, methadone, buprenorphine, I used to be addicted to heroin and made
codeine, etc.) several attempts to cut down, but I man-
aged to stop using completely about 3
years ago so I havent used any opioids
in the last 3 months
j Other specify: kava Only tried kava once years ago, havent
used since
APPendIx g ClIenT SCrIPT Who ASSIST v3.1 ( dAve) reSPonSeS for PAIred role Pl Ay 63
QuESTION 3 | During the past three months, how often have you had a strong desire
or urge to use(first drug, second drug, etc)?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Every day
e Amphetamine-type stimulants (speed, meth, ecstasy, etc.) (Havent used last 3 months)
f Inhalants (nitrous, glue, petrol, paint thinner, etc.) (Never tried inhalants)
QuESTION 4 | During the past three months, how often has your use of (first drug,
second drug, etc) led to health, social, legal or financial problems?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) I wake up with a really bad cough once
or twice a week. Ive been like that for
about 2 years
c Cannabis (marijuana, pot, grass, hash, etc.) Last month the police gave me a caution
for possessing marijuana, but nothing
else really
e Amphetamine-type stimulants (speed, meth, ecstasy, etc.) (Havent used last 3 months)
f Inhalants (nitrous, glue, petrol, paint thinner, etc.) (Never tried inhalants)
QuESTION 5 | During the past three months, how often have you failed to do what
was normally expected of you because of your use of (first drug, second drug, etc)?
a Tobacco products
c Cannabis (marijuana, pot, grass, hash, etc.) Two months ago I forgot to attend an
important family event because I was
smoking marijuana all day. My family
were very angry at me because of it.
e Amphetamine-type stimulants (speed, meth, ecstasy, etc.) (Havent used last 3 months)
f Inhalants (nitrous, glue, petrol, paint thinner, etc.) (Never tried inhalants)
QuESTION 6 | Has a friend or relative or anyone else ever expressed concern about
your use of (first drug, second drug, etc)?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Yes, but not in the past 3 months
c Cannabis (marijuana, pot, grass, hash, etc.) Yes, about 6 months ago
f Inhalants (nitrous, glue, petrol, paint thinner, etc.) (Never tried inhalants)
i Opioids (heroin, morphine, methadone, buprenorphine, Yes, but it was years ago
codeine, etc.)
QuESTION 7 | Have you ever tried to cut down on using (first drug, second drug, etc)
but failed?
a Tobacco products (cigarettes, chewing tobacco, cigars, etc) Yes, I tried last month but failed
c Cannabis (marijuana, pot, grass, hash, etc.) Ive never tried to stop
f Inhalants (nitrous, glue, petrol, paint thinner, etc.) (Never tried inhalants)
QuESTION 8 | Have you ever used any drug by injection Yes, but not in the past 3 months
(non-medical use only)?
The type of intervention is determined by the patients specific substance involvement score
b Alcohol 2 0 10 11 26 27+
c Cannabis 24 03 4 26 27+
d Cocaine 0 03 4 26 27+
e ATS 0 03 4 26 27+
f Inhalants 0 03 4 26 27+
g Sedatives 0 03 4 26 27+
h Hallucinogens 2 03 4 26 27+
i Opioids 6 03 4 26 27+
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Total
Daily Daily Weekly Y/N 3m Y 3m
a Tobacco Yes NA 27
6 6 6 3 6
IMPORTANT NOTE
Y/N 3m means; Yes, but not in the past 3 months (score of 3).
O-T means; Once or Twice.
Y 3m means; Yes, in the past 3 months (score of 6).
Q1 and Q8 are not included in the scoring.
referenCeS 67
References
13 World Health Organization (2002). The 19 Humeniuk RE, Henry-Edwards S and Ali
World Health Report 2002. Reducing Risks, RL (2003). Self-help Strategies for Cutting
promoting healthy life. Geneva, WHO. Down or Stopping Substance Use: A guide.
Draft Version 1.1 for Field Testing. Geneva,
14 Brown RL and Rounds LA (1995). Conjoint
World Health Organization.
screening questionnaires for alcohol and
other drug abuse: criterion validity in a 20 World Health Organization (2009). Global
primary care practice. WMJ, 94:135-140. health Risks. Geneva, WHO.
15 Humeniuk R (2006). Validation of the 21 Institute of Medicine (1990). Broadening
alcohol, smoking and substance involvement the base of treatment for alcohol problems.
screening test (ASSIST) and pilot brief Washington DC, National Academic Press.
intervention: A technical report of phase
22 Skinner HA (1987). Early detection of
II findings of the WHO ASSIST Project.
alcohol & drug problems why? Australian
Geneva, World Health Organization.
Drug & Alcohol Review, 6:293-301.
16 Newcombe D, Humeniuk RE and Ali, RL
23 Royal Australian College of General
(2005). Validation of the World Health
Practitioners (1998). Putting prevention into
Organization alcohol smoking and
practice. A guide for the implementation of
substance involvement screening test
prevention in the general practice setting.
(ASSIST): Phase II study. Report from
1st ed. Melbourne, RACGP.
the Australian site. Drug and Alcohol
Review, 24(3):217-226. 24 Royal Australian College of General
Practitioners (2002). Guidelines for
17 Bien TH, Miller WR and Tonigan S (1993).
preventive activities in general practice.
Brief intervention for alcohol problems: A
2nd ed. Melbourne, RACGP.
review. Addiction, 88:315-336.
25 Humeniuk RE, Henry-Edwards S, Ali RL and
18 Miller W and Rollnick S (2002). Motivational
Meena S (2010). Self-help strategies for
Interviewing. 2nd ed. New York and London,
cutting down or stopping substance use: a
Guilford Press.
guide. Geneva, World Health Organization.
Assist
The WHO ASSIST project aims to support and promote screening and brief
interventions for psychoactive substance use by health professionals to
facilitate prevention, early recognition and management of substance use
disorders in health care systems with the ultimate goal of reducing the The Alcohol, Smoking and Substance
disease burden attributable to psychoactive substance use worldwide.
Involvement Screening Test (ASSIST)
Manual for use in primary care