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1.
What is the Addiction Severity Index? 1. What is the Addiction Severity Index? The Addiction Severity Index (ASI) is a semi-structured instrument used in a face-to face patient interview conducted by a clinician, researcher, or trained technician. A. Thomas McLellan, Ph.D. and colleagues at the University of Pennsylvania developed it in 1980. The ASI covers seven (7) important areas of a patient’s life: medical, employment/support, drug and alcohol use, legal, family/social, and psychiatric. The instrument is designed to obtain lifetime information about problem behaviors as well as focusing specifically on the 30 days prior to assessment. The ASI has high reliability and validity, as confirmed in studies published in leading journals. It is a widely used addiction assessment tool throughout the United States and other countries. Back to TopThe ASI was created in 1980 to enable clinical researchers at the University of Pennsylvania to evaluate treatment outcome in a six-program, substance abuse treatment network, with patients at the V.A. Medical Center. Since the programs were quite different, the ASI had to be fairly generic. The budget for the project was small and the data had to be collected by technicians rather than health care professionals. Because the clinical data had to be collected in a relatively short period of time, the instrument had to focus on a minimum number of questions, relevant to treatment planning. Finally, in order to measure outcome, the questions had to cover a broad range of areas that represent problems associated with drug abuse, which could also be affected by substance abuse treatment. The format had to be suitable for repeat administration at follow-up contacts. Back to Top3. How can a facility benefit by using the ASI? Users of the ASI have noted the following benefits: · provides a comprehensive, standardized psychosocial history in 45-60 minutes · assists in developing a treatment plan and in matching patients to treatment services (not · necessarily to treatment modality or level of care) · is designed for patient follow-ups, allowing programs to monitor treatment effectiveness · is easily administered by trained personnel · is easily adapted for special populations Back to Top4. How is the information collected and recorded? The information usually is collected through a face-to-face interview with a patient. Responses are recorded on the ASI instrument. While the ASI enables the clinician/researcher to collect important assessment information, it also incorporates the patient’s evaluation of his/her need for treatment in each of the seven (7) areas of the instrument. The objective and subjective data are combined to derive measures of problem severity for each of these areas. A 10-point interviewer severity rating scale is used for clinical and treatment planning purposes. Key objective items are combined in a mathematically computed composite score for use as outcome measures in program evaluation and treatment effectiveness studies. (ASI software used for clinical/research purposes can be purchased through an independent vendor.) When good rapport is established with the patient, the ASI helps the interviewer by: · enhancing objectivity · posing questions the interviewer might not normally ask, thereby uncovering important · diagnostic information · identifying problems in major areas of the patient’s life · alerting the interviewer to inconsistencies among information obtained in different areas and providing ways to probe areas that are inconsistent, unclear, or incomplete identifying the need for referral to treatment · assisting the interviewer to develop an initial treatment plan. The complete ASI instrument is used at assessment (baseline), while an abbreviated version, used in a face-to-face patient interview or conducted on the telephone by a trained interviewer, is used for follow-up purposes. Back to Top5. What are the limitations of the ASI? The ASI cannot currently be self-administered (by patients, a self administered version is currently being evaluated). It relies primarily on self-reporting to the interviewer. Also, it is not appropriate for use with adolescents. (The Comprehensive Adolescent Severity Index - CASI was developed by Cathy Meyers Ph.D.) Because the ASI focuses on the 30 days prior to assessment, it has decreased value with psychiatric patients or inmates who have been hospitalized / institutionalized for extended periods of time. When used with these populations, the ASI can capture lifetime problems, but it cannot obtain a true baseline and, therefore, cannot be used to measure change over time. Back to TopThe ASI has good reliability and validity when administered by a trained individual under appropriate conditions. Without standardized training, many of the ASI’s potential benefits can be lost. The standardized training developed and refined by Thomas H. Coyne is a modified and enhanced version of the training that was developed at the University of Pennsylvania. The Goal of the training is: To Develop and or Enhance Interviewer Competencies in Correctly Utilizing the Addiction Severity Index. This Goal is accomplished by achieving the following objectives. · Introducing the rationale and benefits of standardized instruments, the ASI in particular, in the assessment process, i.e matching clients to treatment, making patient placement decisions, managing treatment programs based on assessment data and outcomes, need for performance indicators and the overall need for and importance of outcomes data. · Identify the specific intention of each question asked in the ASI. · Phrase each question in the most efficient way while remaining flexible enough to adapt the questionnaire to specific clients. · Verify information through the use of cross checking. · Understand the importance of the use of additional probes to augment information provided by the client. · Consistently apply the correct numerical codes in response to client answers. · Utilize the severity rating procedure. The ASI developers strongly caution against use of the ASI without adequate training or in ways that are inconsistent with its design (e.g., as a questionnaire). Inappropriate use poses risks to the interpretation of clinical or research findings. Back to Top7. What is the design and length of a standard ASI training? The design and length of training varies site to sire depending on what type of training an organization wants and needs. The type of training depends on factors like what will the data collected be uses for, who will administer the instrument, will follow ups be done, are you using the severity ratings etc.. There is Standard Two Day ASI training, a Standard One Day Booster Session, Training for Administrators, Directors and Supervisors, Computer Training and How to use the ASI to make Patient Placement Decisions. Training can be conducted at your site or other suitable facility. Training is available for 12 - 20 trainees. It generally focuses on intent, interpretation and phrasing of ASI questions, skill-building exercises, role plays, use of data collected to develop severity ratings, developing treatment plans and making patient placement decisions. See Training for descriptions of trainings. Back to Top8. What is the difference between the ASI and the ASI Lite? The ASI Lite is a shortened version of the standard Fifth Edition Addiction Severity Index (ASI), developed by A. Thomas McLellan, Ph.D. and colleagues at the University of Pennsylvania. The ASI Lite was developed in early 1997, in response to numerous requests from the substance abuse field. The primary difference is that the interviewers severity ratings were removed from each section and a 22 other questions were removed and the family history “grid” has been omitted. However all questions that are necessary to compute composite scores remain intact. There is currently another version of the ASI Lite called the ASI Lite CF (Clinical Factors Version) ….. Back to Top9. Why was the ASI Lite developed? To answer this question, we need to remember that the Addiction Severity Index was created in 1980 to enable clinical researchers to evaluate treatment outcomes in a six-program, substance abuse treatment network, with patients at the Philadelphia V.A. Medical Center. Its original purpose was to serve as a standardized data collection instrument. Given its demonstrated reliability and validity, the ASI quickly became the assessment instrument of choice by substance abuse researchers all over the world. Only recently have clinicians begun to see its value as an intake assessment instrument that can be used to develop a treatment plan. A number of factors entered into the decision to develop the ASI Lite. In keeping with the growing demand to measure treatment effectiveness, many state substance abuse agencies are now requiring their funded programs to use the Addiction Severity Index. Since treatment programs need to complete a number of data collection forms on each patient admitted to treatment, adding a full ASI to their existing paperwork requirements could be prohibitive. The ASI Lite meets the minimum requirements needed to conduct outcomes research. Back to Top10. What's the difference between severity ratings and composite scores? Severity ratings are subjective estimates of patient status. They were developed to allow a trained interviewer to estimate problem severity in each of the ASI areas, using a ten-point scale. These ratings have been shown to produce reliable and valid estimates of patient status in each area, and are of great practical value in (1) summarizing the patient's overall status at treatment admission; and (2) formulating an initial treatment plan. However, despite their reliability and validity, severity ratings are subjective estimates, are based in part on lifetime data and, as such, are not appropriate as criteria for measuring change over time. Composite scores are calculated by combining selected objective data from each ASI problem area (section). The developers used an empirical method of combining those items from each ASI problem area which were capable of showing change and which were well related to each other. These measures are mathematically derived and have shown reliability and validity in several settings. For more complete information, researchers are encouraged to refer to the ASI Composite Scores Manual. Back to Top11. How does a treatment program know which version of the ASI to use? If a treatment program wants to use the ASI as the only (or primary) assessment instrument, it should use the standard Fifth Edition ASI, developed in 1990. The standard ASI, when used by a properly trained individual, provides the lifetime and recent history information needed to help the clinician develop an individualized treatment plan. If, on the other hand, the ASI is being added to a number of other assessment / data collection forms, the ASI Lite is recommended. Back to Top12. In conducting ASI follow-up interviews, should severity ratings be used? Many programs conducting research studies now employ trained interviewers to conduct ASI follow-up interviews on the phone. The ASI Q-by-Q Manual, Fifth Edition and the Follow-up Procedures both describe how to conduct ASI follow-up interviews. Because severity ratings are ultimately subjective estimates; because they incorporate "lifetime" items that do not change; and because they are not valid when done over the phone, PLEASE DO NOT USE SEVERITY RATINGS AT FOLLOW-UP AS OUTCOME MEASURES. Back to Top13. What's the best way to add questions to the ASI? In order to make the ASI more responsive to the needs of special populations, many programs add questions to various ASI problem areas (sections). The ASI developers recommend the following guidelines: (1) Do NOT omit any of the questions from the ASI. (2) Do NOT change the original numbering of questions on the ASI. (3) Add questions at the end of each section, before the questions that utilize the patient rating scales -- OR -- insert questions where they flow best with the existing ASI questions, and number them "3a, 3b, " or start with the next number at the end of each section. Program administrators who are interested in adapting the ASI for their special populations are encouraged to read A Guide to Adapting the Addiction Severity Index for Special Populations, by Deni Carise, Ph.D., and A. Thomas McLellan, Ph.D. Back to Top14. Can I use the ASI to make patient placement decisions (i.e. ASAM)? The ASI is a very useful instrument in the collection of patient information that can be used to “assist” in making placement decisions. However it is strongly recommended that you use additional questions necessary to make a more informed and accurate placement. Back to Top15. Do severity ratings correspond to levels of care? NO! There is no correlation of severity ratings to levels of care or patient placement decisions. Back to Top16. Can you use severity ratings as an outcome measure? Because severity ratings are ultimately subjective estimates; DO NOT USE SEVERITY RATINGS AS OUTCOME MEASURES. Back to Top17. Does it have to be an Interview? This is perhaps the most often asked question regarding the ASI. In the search for faster and easier methods of collecting data many clinicians and researchers have asked for a self-administered (either by computer or paper and pencil) version of the instrument. We have seen no convincing demonstration that the interview format produces worse (less reliable or valid) information than other methods of administration and we have found that particularly among some segments of the substance abusing population (e.g. the psychiatrically ill, elderly, confused and physically sick) the interview format may be the only viable method for insuring understanding of the questions asked. Particularly in the clinical situation, the general demeanor or "feel" of a patient is poorly captured without person-to-person contact and this can be an important additional source of information for clinical staff. At this writing there are several self-administered versions under evaluation. Back to Top18. Is there a Self Administered Version of The ASI? There is a Self Administered Version of the ASI that is currently being tested in several states around the country. The self-administered version is being tested for reliability, validity and ease of use among patient populations. Problems of illiteracy among some segments of the substance abusing population continue to be a major concern for those that would be using the self-administered version. Even among the literate there could be problems of attention, interest and comprehension that are especially relevant to this population. However there have been some initial positive experiences reported regarding the use of the self-administered ASI among both patients and staff. Patients have reported that they do not feel as if they are being judged by the interviewer and feel less inhibited to give more honest responses. Some staff has reported that they feel they can now spend more time focusing on problems then simply identifying them. There are of course many useful, valid and reliable self-administered instruments appropriate for the substance abuse population. For example, we have routinely used self-administered questionnaires and other instruments with very satisfactory results (e.g. Beck Depression Inventory, MAST, SCL-90, etc.) but these are usually very focused instruments that have achieved validity and consistency by asking numerous questions related to a single theme (e.g. depression, alcohol abuse, etc.). Back to Top19. What are the qualifications needed for an ASI interviewer? Having indicated the importance of the interview process it follows that the most important part of the ASI is the interviewer who collects the information. The interviewer is not simply the recorder of a series of subjective statements. The interviewer is responsible for the integrity of the information collected and must be willing to repeat, paraphrase and probe until he/she is satisfied that the patient understands the question and that the answer reflects the best judgment of the patient, consistent with the intent of the question. It must be emphasized that the interviewer must understand the intent of each question. This is very important since despite the range of situations and unusual answers that we have described in the manual, a new exception or previously unheard of situation occurs virtually each week. Thus, ASI interviewers should not expect to find answers in the workbook to all of the unusual situations that they will encounter in using the ASI. Instead it will be critical for the interviewer to understand the intent of the question, to probe for the most complete information available from the patient and then to record the most appropriate answer, including a comment. There is a very basic set of personal qualities necessary for becoming a proficient interviewer. First, the prospective interviewer must be personable and supportive - capable of forming good rapport with a range of patients who may be difficult. It is no secret that many individuals have negative feelings about substance abusers and these feelings are revealed to the patients very quickly, thereby compromising any form of rapport. Second, the interviewer must be able to help the patient separate the problem areas and to examine them individually using the questions provided. Equally important qualities in the prospective interviewer are the basic intelligence to understand the intent of the questions in the interview and the commitment to collecting the information in a responsible manner. There are no clear-cut educational or background characteristics that have been reliably associated with the ability to perform a proficient ASI interview. We have trained a wide range of people to administer the ASI, including receptionists, college students, police/probation officers, physicians, professional interviewers and research psychologists. There have been people from each of these groups who were simply unsuited to performing interviews and were excluded during training (perhaps 10% of all those trained) or on subsequent reliability checks. Reasons for exclusion were usually because they simply couldn't form reasonable rapport with the patients, they were not sensitive to lack of understanding or distrust in the patient, they were not able to effectively probe initially confused answers with supplemental clarifying questions or they simply didn't agree with the approach of the ASI (examining problems individually rather than as a function of substance abuse). With regard to assisting the interviewer in checking for understanding and consistency during the interview, there are many reliability checks built into the ASI. They are discussed in some detail in the workbook and they have been used effectively to insure the quality and consistency of the collected data. Back to Top20. Severity Ratings, how important and useful are they? It is noteworthy that the severity ratings were historically the last items to be included on the ASI. They were considered to be interesting but non-essential items that were a summary convenience for people who wished a quick general profile of a patient's problem status. They were only provided for clinical convenience and never intended for research use. It was surprising and interesting for us to find that when interviewers were trained comparably and appropriately, these severity estimates were reliable and valid across a range of patient types and interviewer types. Further, they remain a useful clinical summary that we continue to use regularly - but only for initial treatment planning and referral. A Note on "Severity" - It should be noted that much of the reason for the reliability and validity of these severity ratings is the structured interview format and the strict (some would say arbitrary) definition of severity that we have adopted: ie."need for additional treatment." Many users of the ASI have selected the instrument exclusively for research purposes and these ratings have never been used for this purpose - especially as outcome measures. Other users do not agree with our definition of severity. Still others do not have the time or inclination to check and recheck severity estimates among their various interviewers. For all of these potential users the severity ratings would not be useful or worth the investment of man-hours required to train reliability. Even for those with primary clinical uses, these ratings are not essential and are perhaps the most vulnerable of all the ASI items to the influences of poor interviewing skills, patient misrepresentation or lack of comprehension and even the surroundings under which the interview is conducted. Therefore, it is entirely acceptable to train ASI interviewers and to use the ASI without referral to the severity ratings. Back to Top21. What are Composite Scores, what are they used for and why were they constructed this way and what are the norms? Users familiar with earlier editions of the ASI know there is a separate manual designed to describe their use and to show how to calculate them (See Composite Scores from the Addiction Severity Index - McGahan et al. 1986). The composite scores have been developed from combinations of items in each problem area that are capable of showing change (ie. based on the prior thirty day period, not lifetime) and that offer the most internally consistent estimate of problem status. The complicated formulas used in the calculation of these composites are necessary to insure equal weighting of all items in the composite. These composites have been very useful to researchers as mathematically sound measures of change in problem status but have had almost no value to clinicians as indications of current status in a problem area. This is due to the failure on our part to develop and publish normative values for representative groups of substance abuse patients (e.g. methadone maintained males, cocaine dependent females in drug free treatment, etc.). At the risk of being defensive, our primary interest was measuring change among our local patients and not comparing the current problem status of various patient groups across the country. Further, we simply did not foresee the range of interest that has been shown in the instrument. A Note on "Norms" for the Composite Scores - At this writing, we are collecting ASI data from a variety of patient samples across the country. These samples will be used to convert the composite raw scores into T-scores with a mean of 50 and a standard deviation of 10 (as MMPI and SCL-90 scores are presented). Our intention is to publish these "normative data" and to circulate copies of the tables to all individuals who have sent to us for ASI packets. Back to Top22. Can I use the ASI with samples of Substance Abusing Prisoners or Psychiatrically Ill Substance Abusers? Because the ASI has been shown to be reliable and valid among substance abusers applying for treatment, many workers in related fields have used the ASI with substance abusing samples from their populations. For example, the ASI has been used at the time of incarceration and/or parole/probation to evaluate substance abuse and other problems in criminal populations. In addition, because of the widespread substance abuse among mentally ill and homeless populations, the ASI has also been used among these groups. While we have collaborated with many workers on the use of the instrument with these populations; it should be clear that there are no reliability or validity studies of the instrument in these populations. This of course does not mean that the ASI is necessarily invalid with these groups, only that its test parameters have not been established. In fact, workers from these fields have turned to the ASI because they felt that no other suitable instrument was available. In cases where this is true, it is likely that the ASI would be a better choice than creating a totally new instrument. However, it is important to note circumstances that are likely to reduce the value of data from the ASI among these groups. For example, when used with a treatment seeking sample and an independent, trained interviewer, there is less reason for a potential substance abuser to misrepresent (even under these circumstances it still happens). In circumstances where individuals are being "evaluated for probation/parole or jail” there is obviously much more likelihood of misrepresentation. Similarly, when the ASI is used with psychiatrically ill substance abusers that are not necessarily seeking (and possibly avoiding) treatment, there is often reason to suspect denial, confusion and misrepresentation. Again, there is currently no suitable alternative instrument or procedure available that will insure valid, accurate responses under these conditions. The consistency checks built into the ASI may even be of some benefit in these circumstances. However, it is important to realize the limits of the instrument. Back to Top23. Can I Use The ASI With Adolescent Populations? Despite the fact that we have repeatedly published warnings for potential users of the ASI regarding the lack of reliability, validity and utility of the instrument with adolescent populations there remain instances where the ASI has been used in this inappropriate manner. Again, the ASI is not appropriate for adolescents due to its underlying assumptions regarding self-sufficiency and because it simply does not address issues (e.g. school, peer relations, family problems from the perspective of the adolescent, etc.) that are critical to an evaluation of adolescent problems. Back to Top24. Can I ask additional questions and/or delete some of the current items? As indicated above, the ASI was designed to capture the minimum information necessary to evaluate the nature and severity of patients' treatment problems at treatment admission and at follow-up. For this reason, we have always encouraged the addition of particular questions and/or additional instruments in the course of evaluating patients. In our own work we have routinely used additional questionnaires, additional family background questions and some self-administered psychological tests. Back to Top25. Can I delete some of the current items? We do not endorse the elimination or substitution of items currently on the ASI. Again, the ASI items (regardless of whether they are good or bad for particular individual needs) have been tested for reliability and validity as individual items and as part of the composite and/or severity scores. The elimination or substitution of existing items could significantly reduce the reliability and comparability of these ASI scores. It is possible to eliminate whole sections (problem areas) of the ASI if particular problems are not applicable for specific populations or the focus of specific treatment interventions. Back to Top |