Substance Screening

Recommended approach: Use AUDIT-C + DAST-10 together for complete substance use screening. See references/screening-comparison.md for detailed guidance.

Assessment Selection Decision Tree

digraph assessment_selection {
    rankdir=TB;
    node [shape=box, style=rounded];

    start [label="Substance Use\nScreening", shape=ellipse];
    both [label="SCREEN BOTH:\nAUDIT-C (alcohol)\n+\nDAST-10 (drugs)", style="filled", fillcolor=lightblue];

    audit_result [label="AUDIT-C\nPositive?", shape=diamond];
    dast_result [label="DAST-10\nPositive?", shape=diamond];

    alcohol_only [label="Alcohol Use\nIssue Only", style="filled", fillcolor=yellow];
    drugs_only [label="Drug Use\nIssue Only", style="filled", fillcolor=yellow];
    both_positive [label="Both Alcohol\nAND Drugs", style="filled", fillcolor=orange];
    neither [label="Negative\nScreens\nRoutine f/u", style="filled", fillcolor=lightgreen];

    full_audit [label="Consider\nFull AUDIT\n(if AUDIT-C ≥6)", shape=box];
    intervention [label="Brief\nIntervention\nor\nReferral", style="filled", fillcolor=lightblue];

    start -> both;
    both -> audit_result;
    audit_result -> dast_result [label="yes"];
    audit_result -> dast_result [label="no"];

    dast_result -> both_positive [label="AUDIT yes\nDAST yes"];
    dast_result -> alcohol_only [label="AUDIT yes\nDAST no"];
    dast_result -> drugs_only [label="AUDIT no\nDAST yes"];
    dast_result -> neither [label="both no"];

    alcohol_only -> full_audit;
    drugs_only -> intervention;
    both_positive -> intervention;
    full_audit -> intervention;
}

Interactive Administration (Optional)

Use this mode when the clinician says "start" or "administer" AUDIT-C and/or DAST-10.

1. Confirm whether to administer AUDIT-C, DAST-10, or both (recommended: both).
2. Explain the time frame and response format for each instrument.
3. Ask one item at a time (verbatim from the asset file) and wait for a response before continuing.
4. Accept numeric or verbal responses; if unclear or out of range, ask for clarification.
5. Record each response and keep running totals (remember DAST-10 Item 3 is reverse scored).
6. After each instrument, calculate totals, interpret severity, and provide next-step guidance.
7. Offer a brief documentation summary if requested.

Usage

Example requests: "Screen for alcohol use", "Administer DAST-10", "Score AUDIT-C", "Interpret substance screening"

Quick Reference: Severity Levels

AUDIT-C Interpretation (Alcohol)

Men:

• 0-3: Low risk - Annual rescreening
• 4-5: Hazardous drinking - Brief intervention
• 6-7: Harmful/high risk - Brief intervention + full AUDIT, consider referral
• 8-12: Severe risk - Specialty addiction treatment referral required

Women:

• 0-2: Low risk - Annual rescreening
• 3-4: Hazardous drinking - Brief intervention
• 5-7: Harmful/high risk - Brief intervention + full AUDIT, consider referral
• 8-12: Severe risk - Specialty addiction treatment referral required

DAST-10 Interpretation (Drugs)

• 0-2: No/minimal risk - Routine monitoring
• 3-5: Moderate risk - Comprehensive assessment, consider outpatient treatment
• 6-8: Substantial risk - Specialty addiction treatment referral required
• 9-10: Severe risk - Immediate specialty referral, higher level of care

For detailed severity interpretations and treatment recommendations, see references/severity-levels.md

Assessment Administration

AUDIT-C (Alcohol Use Disorders Identification Test - Concise)

Complete details: assets/audit-c.md

Items (0-4 each): 1) Drinking frequency, 2) Drinks per day, 3) Binge drinking frequency

Scoring: Total 0-12. Men ≥4, Women ≥3 = positive. Standard drink: 12oz beer, 5oz wine, 1.5oz spirits.

Next Steps: Below cutoff → annual rescreen. 4-7 (M) or 3-7 (W) → brief intervention, f/u 1-3mo. ≥8 → full AUDIT + referral.

DAST-10 (Drug Abuse Screening Test - 10 Item)

Complete details: assets/dast-10.md

Format: 10 Yes/No questions, past 12 months, excludes alcohol/tobacco. Covers use beyond medical reasons, polysubstance, loss of control, blackouts, guilt, family issues, illegal activities, withdrawal, medical complications. Item 3 reverse scored.

Scoring: Total 0-10. 1 point per "Yes" (except Item 3). ≥3 = problematic use.

Next Steps: 0-2 → monitor. ≥3 → detailed history (substances, frequency, route). Opioids → MAT discussion. Injection use → infectious disease screening.

Clinical Decision-Making

Severity to Intervention Pathway

digraph severity_intervention {
    rankdir=TB;
    node [shape=box, style=rounded];

    audit [label="AUDIT-C\nScore", shape=ellipse];
    dast [label="DAST-10\nScore", shape=ellipse];

    audit_low [label="0-3 (Men)\n0-2 (Women)", shape=box];
    audit_haz [label="4-5 (Men)\n3-4 (Women)", shape=box];
    audit_harmful [label="6-7 (Men)\n5-7 (Women)", shape=box];
    audit_severe [label="≥8", shape=box];

    dast_low [label="0-2", shape=box];
    dast_mod [label="3-5", shape=box];
    dast_sub [label="6-8", shape=box];
    dast_severe [label="9-10", shape=box];

    tx_none [label="Annual\nRescreening", style="filled", fillcolor=lightgreen];
    tx_brief [label="Brief\nIntervention\n(5-15 min)", style="filled", fillcolor=yellow];
    tx_bi_refer [label="Brief Intervention\n+ Full AUDIT\n+ Consider Referral", style="filled", fillcolor=orange];
    tx_specialty [label="Specialty\nAddiction\nTreatment", style="filled", fillcolor=red, fontcolor=white];

    tx_monitor [label="Routine\nMonitoring", style="filled", fillcolor=lightgreen];
    tx_assess [label="Comprehensive\nAssessment\nOutpatient Option", style="filled", fillcolor=yellow];
    tx_refer [label="Specialty Referral\nMAT if Opioids", style="filled", fillcolor=orange];
    tx_immediate [label="Immediate Referral\nHigher LOC", style="filled", fillcolor=red, fontcolor=white];

    audit -> audit_low;
    audit -> audit_haz;
    audit -> audit_harmful;
    audit -> audit_severe;

    dast -> dast_low;
    dast -> dast_mod;
    dast -> dast_sub;
    dast -> dast_severe;

    audit_low -> tx_none;
    audit_haz -> tx_brief;
    audit_harmful -> tx_bi_refer;
    audit_severe -> tx_specialty;

    dast_low -> tx_monitor;
    dast_mod -> tx_assess;
    dast_sub -> tx_refer;
    dast_severe -> tx_immediate;
}

For structured clinical decision trees covering screening pathways, treatment selection, withdrawal management, and co-occurring disorders, see references/clinical-decision-trees.md

Substance-Specific: Opioids: MAT immediately (buprenorphine, methadone, naltrexone), naloxone for all. Stimulants: Behavioral therapies, cardiac/psychiatric evaluation. Benzodiazepines: Never abrupt stop (seizure risk), supervised taper required.

Brief Intervention for Positive AUDIT-C (4-7 range)

Components (5-15 min): Provide feedback (compare to low-risk guidelines), assess readiness, set goals, provide resources, follow-up in 1-3 months. Low-risk limits: Men ≤14/week, ≤4/day; Women ≤7/week, ≤3/day.

Safety Protocols

Approach: Non-judgmental, confidential. Normalize screening, use non-stigmatizing language.

Immediate Concerns: Acute intoxication/withdrawal → medical evaluation. Alcohol/benzodiazepine withdrawal → supervised detox (seizure risk). Opioids → MAT + naloxone. Injection use → infectious disease screening. Suicidal ideation → crisis intervention per ../../docs/references/crisis-protocols.md.

Crisis Resources: SAMHSA 1-800-662-4357, 988 Lifeline, Text HOME to 741741, Emergency 911

Documentation

AUDIT-C template: assets/audit-c.md - Include 3 items, score, gender/cutoff, result, risk level, brief intervention, follow-up.

DAST-10 template: assets/dast-10.md - Include 10 items, score, risk level, substances, red flags (injection/opioids/withdrawal), recommendations, safety, naloxone if needed.

Standards: ../../docs/references/documentation-standards.md

Limitations & Considerations

Support tool, not diagnostic: Self-report may underestimate use. Requires clinical context interpretation. Cultural factors affect disclosure. Clinical judgment supersedes scores. Use non-judgmental, motivational approach. Avoid stigmatizing language; use "person with substance use disorder," "person in recovery."

Special Populations: Pregnancy (immediate perinatal referral), adolescents (use CRAFFT), older adults (lower cutoffs, medication interactions), chronic pain (assess prescription use).

Comorbidity: High rates of depression (30-50%), anxiety (20-30%), PTSD (30-50%), suicidal ideation. Screen with ../../depression-screening/, ../../anxiety-screening/, ../../trauma-screening/, ../../suicide-screening/. Integrated treatment required.

Workflow Integration

Related workflows: ../../intake-interview/ (comprehensive intake), ../../treatment-planning/ (substance treatment plans), ../../documentation/ (progress notes). See ../../docs/references/crisis-protocols.md and ../../docs/references/referral-guidelines.md.

Additional Resources

Detailed guidance: references/severity-levels.md, references/screening-comparison.md, references/clinical-decision-trees.md

External: https://findtreatment.gov (SAMHSA), https://aa.org, https://na.org, https://smartrecovery.org

References

AUDIT-C:

• Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158(16):1789-1795.
• Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208-1217.

DAST-10:

• Skinner HA. The drug abuse screening test. Addict Behav. 1982;7(4):363-371.
• Yudko E, Lozhkina O, Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat. 2007;32(2):189-198.

Freely available for clinical and research use