WHY THE ASI SHOULD BE REPLACED AND WHY MANDATES FOR ITS USE SHOULD BE ELIMINATED

WHY THE ASI SHOULD BE REPLACED AND WHY MANDATES FOR ITS USE SHOULD BE ELIMINATED The ASI (Addiction Severity Index) was initially designed as a program evaluation tool for VA populations and subsequently has been used as a basis for determining indications of effectiveness of treatment programs and various societal benefits from the effective treatment of substance use disorders in a variety of settings. Improvements regarding substances are measured in terms of days of use in the past 30 and other areas likely to be impacted by substance use disorders are assessed on reductions/improvements in that same timeframe. As an evaluation instrument, the ASI should be administered following routine initial clinical assessments that cover diagnostic determinations and treatment planning/placement assessments. Mandates by state agencies to use the ASI as an intake instrument to standardize intake are totally inappropriate. The ASI is designed to make a pre vs. post comparison of use and problems rather than to provide clinically actionable information at intake. Time spent gathering ASI data could be better spent in doing assessments that are actually required for clinical practice. Since reimbursements often are insufficient to cover both the time spent doing the ASI and the clinical assessments necessary for good clinical practice there may be pressure to skimp or take shortcuts in both areas. Unless there will be follow- up contact to make comparisons to assess treatment impacts, the use of the ASI is inappropriate. Indeed mandating the use of the ASI only as an intake instrument may have become one of the major impediments to improving the quality of assessments and treatment in many states. A much more defensible and pragmatic approach to the administrative need states may have to gather information on the nature and extent of problems at intake and in documenting outcomes in a routine way is to mandate the content and format of the information to be collected. This would then allow clinicians and programs to collect data in the most appropriate, efficient, and accurate way possible. For example, one might mandate that the programs document whether clients manifest a substance use disorder for each of the substance categories of the current diagnostic criteria. Or one could even have them quantify how many of the diagnostic criteria are positive in a simple data matrix. This would then allow programs to utilize diagnostic tools that are appropriate for their populations to obtain the relevant information from each client. Similarly, programs could be mandated to document certain treatment planning/placement parameters in accordance with criteria in the state, but allow clinicians to determine how that information is to be collected. Outcome information could also be dictated in terms of outcomes of interest, such as remission as defined by the DSM- 5, whether the individual is requiring continuing medical or psychological/psychiatric services, has been arrested, etc. Again, if the parameters of the information to be collected are specified, the specific instrument or procedure required to collect the information vary from program to program, but will still produce the same basic data. WHY THE AIS IS NOT AN APPROPRIATE INTAKE INSTRUMENT General deficiencies of the ASI make it not only inadequate for conducting intakes (assessment and placement), but actually make it a hindrance to good clinical practice. The time spent collecting the ASI data detracts from the limited time clinicians have to identify the nature and extent of the clinical condition(s) and to identify client needs in developing a treatment plan and recommending an appropriate treatment placement. The ASI has no relevant diagnostic information and cannot adequately address any of the six dimensions of the ASAM PPC- 2R for the development of a defensible treatment plan including placement. None of the eleven diagnostic criteria of the DSM- 5 or the criteria of the previous DSM- IV- 1

TR are covered by the ASI in a way to support a diagnosis. Thus, one cannot verify whether severity of the DSM- 5 or abuse vs. dependence of the DSM- IV- TR exist in general or for any specific substance. Placement into a residential program is recommended by the PPC- 2R only if a diagnosis of dependence is identified. A moderate to severe diagnosis of the DSM- 5 might also be appropriate for residential placement, but only a mild diagnosis would not. The ASI provides virtually no relevant information for the six dimensions of the ASAM PPC- 2R despite attempts to infer indications from the ASI data. The deficiencies are outlined by dimension as follows: Dimension 1: The ASI cannot inform the intake worker whether there is likely to be a detoxification or withdrawal problem or how bad it is likely to be. The only exception would be if the individual acknowledges use during all 30 days in combinations of substances that could be problematic, but this is a stretch. Dimension 2: The medical section us insufficient to assess whether the person has a medical condition that will interfere with treatment or requires attention at this time. Dimension 3: The psychiatric section of the ASI cannot definitively identify whether there is a serious emotional problem that requires immediate attention or whether there is an Axis I or II condition that requires attention independent of the addictive disorder. Even the questions about suicide do not adequately provide guidance as to whether the thoughts are current or there is an intent or plan. While some of the questions do address areas of the PPC- 2R or ASAM Criteria of 2014, they do not provide sufficient information for treatment planning. Dimension 4: There is virtually nothing on readiness to change other than the patients ratings of how important treatment is to them. There is no indication that the individuals really recognize the nature or extent of their problems or their willingness to take part in treatment or other recovery efforts. Dimension 5: A number of risk factors based on the existent literature on prognoses can be identified from the ASI, but are not converted into indications of risk levels. Many risk factors noted in the ASAM PPC- 2R or ASAM Criteria are not covered. These include, but are not limited to, severity of craving and physiological/psychological response to substances, levels of engagement by self or others in the recovery effort, ability to recognize relapse triggers or risky situations, and impulsivity relevant to substance use. Dimension 6: The ASI section on family and social relationships covers numerous questions about relationships, but fails to determine whether those individuals are supportive or detrimental to recovery. The only questions that do so pertain to persons the client lives with but not other relatives or friends. In short, there is minimal information on the nature and extent to which the social network and individuals within it are likely to be contusive or detrimental to recovery. In short, the ASI requires a considerable period of time to collect information that might be of administrative interest, but provides little if any true contribution to clinical practice. The time spent conducting the ASI interview detracts from the clinical tasks of identifying problems and their severity and assessing client needs. The ASI is essentially useless unless it is actually used as a program evaluation tool to compare baseline data to outcome data. THE ASI AS A PROGRAM EVALUATION TOOL Aside from the fact that the ASI is not an appropriate intake tool, it also has limitations as an evaluation instrument in the 21 st Century. Obviously, the ASI data are relevant only in the context of an appropriate intake evaluation that apart from the ASI identifies the nature and extent of addictions and possible co- occurring conditions along with a defensible treatment plan as supported by the ASAM PPC- 2

2R, ASAM Criteria, or other clinically acceptable criteria. These limitations are both general and specific to the various scales of the ASI. Major general problems with the ASI as an evaluation tool to be used outside the confines of a rigorous scientific study are the reliance on subjective ratings by the interviewer and the difficulty in scoring the scales. Having been an evaluator for ASI training conducted by an experienced trainer, I discovered that in the post- tests virtually all participants still made mistakes in scoring hypothetical responses, and many had substantial errors after training. This suggests that the consistent use of the ASI requires extensive training for reliable results and is not likely to produce standardized findings from setting to setting, much less state to state when employed in routine clinical practice. Time pressures are likely to create even greater disparities in implementation. A serious limitation of the ASI is the reliance on subjective ratings by the interviewer both in terms of what the respondent has said and observations of indications of emotional problem indications. This presents a serious problem in standardization among interviewers and will require highly trained individuals to produce consistent results for inter- rater reliability. Also the reliance on observational data precludes any phone or Internet contact where such information would not be available. Once the ASI is implemented outside of a rigorous research structure where highly trained research assistants implement and score the instrument at baseline and in face- to- face follow- up interviews, the consistency of the data collection and scoring is questionable at best. Aside from the methodological difficulties regarding implementation of the ASI, there are a number of problems with the content and the measures used. A critical bit of missing information in most of the sections is whether there are positive or negative influences for recovery. Examples of negative influences are, whether any current medical or psychiatric issues (e.g., medications for pain, anxiety, etc.) or workplace stresses might pose problems to recovery. Examples of positive influences missing from the ASI are the level of understanding the individual has of his/her condition(s), family and other supports, and comfort level with self- help support groups. Other deficiencies are discussed for each of the areas covered by the ASI. Drug and Alcohol Use The primary measures of outcome in this area are the days of use in the previous 30 days and the route of administration. The only identified problems remotely related to continuing problems are DT s for alcohol and an overdose on drugs both relatively rare and severe occurrences. Two questions cover self- identified problems but there is no specificity of the severity of the problems other than the extent to which the person is troubled by the problems. The section also includes questions on the longest period of abstinence and when it ended (Coded 0 if still abstinent). Lifetime number of treatments for rehabilitation and detoxification are also covered. There is no reasonable indication of whether the substance use disorder persists other than days of use in the past month and subjective ratings of problems and being troubled by those problems. There is no indication of whether the individual continues to meet diagnostic criteria for the DSM- IV- TR or DSM- 5. There is no indication as to the seriousness of problems associated with use. Days of use are of questionable value. An individual who has a single glass of wine with dinner each evening but has no consequences of the single glass would receive the maximum score on days of use namely 30 days of use in the past 30. In contrast a binge drinker who binges on weekends and continues to meet criteria for alcohol dependence might score only 8 of 30 days despite consequences. The DSM- 5 definition of remission makes the ASI measure of days of use obsolete. Sustained remission is defined as having no positive DSM- 5 criteria other than craving for 12 consecutive months. 3

Use is not part of the remission criteria since this remission definition is suitable for those requiring abstinence to achieve remission as well as for misusers who may be able to moderate use and/or behaviors so as to avoid further problems. A snapshot of the past 30 days cannot determine if remission is achieved or not. The ASI collects a number of variables that are of little value. Asking about the route of administration for alcohol and inhalants seems silly and a waste of time. What would be relevant is to cover whether any substance was injected and to determine if some of the key indicators of dependence are present. At a minimum, some questions regarding common problems in relapse would be appropriate such as failure to fulfill role obligations, objections by others, use beyond intended limits, and withdrawal symptoms. Lifetime admissions to treatment is relevant as an outcome measure only to the extent that it can be compared with the baseline outcome measure to determine if there were subsequent treatments or detoxifications after the index treatment. This requires linking baseline data for a given individual to the outcome data for the same person. The ASI questions on how much a person spends on alcohol and drugs is likely to be highly dependent upon the individual s financial resources. It also does not account for bartering such as trading sex for drugs. In short, the alcohol and drug section provides no useful information on the nature of continuing problems or any indications of positive indications of recovery. There are no questions about whether or not the individual is utilizing self- help groups or other support services or is following a recovery plan developed during treatment. This last point is very important since such engagement is highly correlated to the probability of remission. Medical Status Lifetime number of hospitalizations, like lifetime admissions to treatment, is relevant for outcomes only in comparison to baseline data. A single question asks whether chronic medical problems interfere with your life? There is no information about acute illnesses, outpatient appointments or emergency room visits. The subjective rating of the interviewer as to the need for medical treatment and the rating of days the respondent has experienced medical problems in the past 30 days are the only indications as to any acute or current problem. There is no measure to identify whether the medical condition might interfere with recovery, such as having chronic pain, needing an operation for which pain medications might be prescribed, etc. At best the medical section is a crude approximation of medical needs. It is also a relatively insensitive measure as to whether medical conditions or the need for medical care have decreased after treatment. The only measure on medical care utilization consists of the number of hospitalizations. There are no indications as to days of hospitalization, number of emergency room visits, or outpatient clinic visits. Employment Support status Many of the items in this section focus on income, which is likely to be highly influenced by economic situations at the time of initial and follow- up contacts. In times of economic downturns, income might decrease irrespective of remission status. The entire section seems irrelevant for a stay- at- home spouse, an adolescent living at home, or someone who is retired. 4

As with the medical section, there is no indication as to whether the workplace or lack of employment is beneficial or detrimental to recovery. Likewise there are specifics as to what employment problems the person may have experiences such as absenteeism, performance problems, conflicts with supervisors, etc. Legal Status This section largely deals with lifetime number of arrests and incarcerations. Duration of incarceration is only covered within the past 30 days. Thus, if the individual was incarcerated much of the time in follow- up, this would have to be calculated from lifetime months of incarceration. That variable only allows for up to 99 months, which might not be sufficient if one is dealing with correctional populations. The section has no items to probe whether potential sanctions might influence behavior or motivation for recovery. Similarly, there is no indication as to whether current illegal behaviors might pose a risk for relapse. All measures of frequencies for various offenses must be related to lifetime measures so that the baseline reports need to be subtracted from the follow- up data for each person to determine whether the arrests, charges, etc. occurred subsequent to treatment. Family History This section is essentially of no value for follow- up as it covers whether various family members had a serious alcohol, drug, or psychiatric problem. This might be helpful in estimating genetic loading for addictions or mental illness, but the section would not be expected to change much on follow- up. Family Social Relationships This section covers living arrangements and historical relationships with various family members. It also covers whether the individual experienced serious problems in getting along with relatives either historically or in the past 30 days. Friends and other social networks are not covered at all except for a question about serious conflicts in the past 30 days. Also, there are no items to address whether any individuals are supportive or detrimental to recovery. There are questions about conflicts and victimization (physical, sexual, and emotional abuse), but this no specificity as to who the perpetrator is. In short, this section is relatively uninformative as to whether interpersonal relationships have really improved or not. One could continue to have conflicts because some family members might be detrimental to recovery. Conversely, one might not have conflicts because family members are supportive of recovery or because one has cut ties with family members. Perversely, one might not have conflicts in relapse because one is associating only with those who support use. In other words, the items as presented to not inform us much about the quality of relationships with family members and whether they are positive or negative influences. The only information on friends or others is whether the respondents have had significant periods in which they experienced serious problems getting along with others. As with family members, we do not know if the relationships provide support for recovery are might be detrimental. Psychiatric Status As with the medical section, there are questions about hospitalizations, but outpatient visits are also captured here. Subjective questions about how troubled or important treatment is for emotional conditions are asked. Specific questions for lifetime and in the past 30 days are asked of depression, anxiety, hallucinations, concentration and understanding difficulties, controlling violent behavior, suicidal thoughts and attempted suicide. Subjective ratings by the interviewer are also noted. 5

Again, one has no direct indications as to whether the possible psychiatric condition or problem requires current attention or poses a potential problem for recovery. No attempt is made to capture any indications of PTSD, which is one of the more common co- occurring conditions. Likewise, mania is also seen more commonly among addicted populations than in the general populations, but no information on manic episodes is captured. The reliance on asking about serious problems also opens the door for varied interpretation by the respondent and may result in variable reporting. SUMMARY The ASI has provided indications of benefits derived from treatment and has assisted in making a contribution to the addiction field. However, its continued use is not justified due to the weaknesses of the instrument and the developments in the decades since its latest iteration. A particularly vexing problem is mandating the use of the ASI solely as an intake instrument. It is totally unsuited for this application, and detracts from clinical practices necessary to implement treatment based on current standards of care. The fact that the instrument is free is an insufficient rationale to continue to promote, require, or use the instrument. Administrative goals can be achieved by mandating the collection of information irrespective of the instrument if the mandates are carefully crafted. There are many objective and robust variables or measures that could be collected irrespective of the specific instrument for both baseline and outcome purposes. Any program evaluation tool should be a clinical aid and not a clinical hindrance. This is also true for collection of baseline data for administrative purposes. In other words, the evaluation tool, or database, should rely on information that is routinely collected and is as concrete and objective as possible. The ASI fails this requirement due to subjective ratings in the scoring. In short, the ASI is somewhat analogous to the Model T Ford. The Model T made a significant contribution to the automotive industry and should be recognized for its contribution. However, mandating that state employees all drive a Model T would not be prudent policy in the 21 st Century. 6