Assessing Alcoholism

Alcohol Alert

National Institute on Alcohol Abuse and Alcoholism

No. 12 PH 294 April 1991

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Assessing Alcoholism

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Representative Sources for Assessment
Instruments:

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

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

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

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service * National Institutes of Health

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