Addiction Severity Index User Information The ASI is a multidimentional structured interview introduced by Dr. A. Thomas McLellan in 1980. It is widely used in the United States as a tool for assessing the severity of substance use disorders and for evaluating treatment outcomes. The interview forms, a comprehensive test manual and other user information are available free of charge from http://www.tresearch.org/asi.htm. Special training is needed for interviewers to administer the ASI reliably.
ADDICTION SEVERITY INDEX-Fifth Edition Instructions Leave No Blanks - Where appropriate code items: X=question not answered N=question not applicable Use only one character per item. Space is provided after sections for additional comments. Summary of Subject Rating Scale 0 - Not at all 1 - Slightly 2 - Moderately 3 - Considerably 4 - Extremely MEDICAL STATUS 1. How many days have you experienced medical problems in the past 30? FOR QUESTIONS 2 & 3 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 2. How troubled or bothered have you been by these medical problems in the past 30 days? 3. How important to you now is treatment for these medical problems? Source. McLellan, A. T., Parikh, G., Bragg, A., Cacciola, J., Fureman, B., & Incmikofki, R. (1990). Addiction Severity Index administration manual. Philadelphia, PA: Penn-VA Center for Studies of Addiction. Reproduced by permission. Page 1 of 7
EMPLOYMENT/SUPPORT STATUS 1. Do you have a valid driver's license? 0-No 1-Yes 2. Do you have an automobile available for use? (Answer No if no valid driver's license.) 0-No 1-Yes 3. How many days were you paid for working in the past 30? (Include "under the table" work.) How much money did you receive from the following sources in the past 30 days? 4. Employment (net income) 5. Unemployment compensation 6. DPA 7. Pension, benefits, or social security 8. Mate, family, or friends (money for personal expenses) 9. Illegal DRUG/ALCOHOL USE Past 30 Days Rt of adm. 1. Alcohol-any use at all 2. Alcohol-to intoxication 3. Heroin 4. Methadone 5. Other opiates/analgesics 6. Barbiturates 7. Other sedatives/hypnotics/tranquilizers 8. Cocaine 9. Amphetamines 10. Cannabis 11. Hallucinogens Page 2 of 7
12. Inhalants 13. More than one substance per day (Incl. alcohol) Note: See manual for representative examples for each drug class Route of Administration: 1=Oral 2=Nasal 3=Smoking, 4=Non-IV injection 5=IV injection 14. How many times in the past 30 days have you: Had alcohol d.t.'s Overdosed on drugs 15. How many times in the past 30 days have you been treated for: Alcohol Abuse Drug Abuse 16. How many of these were detox only? Alcohol Drug 17. How much would you say you spent during the past 30 days on: Alcohol Drugs 18. How many days in the past 30 have you experienced: Alcohol Problems Drug Problems FOR QUESTIONS 19 AND 20 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 19. How troubled or bothered have you been in the past 30 days by these: Alcohol Problems Drug Problems 20. How important to you now is treatment for these: Alcohol Problems Drug Problems Page 3 of 7
LEGAL STATUS How many times in the last 6 months have you been arrested and charged with the following: 1. shoplifting/vandalism 2. parole/probation violations 3. drug charges 4. forgery 5. weapons offense 6. burglary, larceny, B & E 7. robbery 8. assault 9. arson 10. rape 11. homicide, manslaughter 12A. prostitution 12B. contempt of court 12C. other 13. How many of these charges resulted in convictions? How many times in the last 6 months have you been charged with the following: 14. Disorderly conduct, vagrancy, public intoxication 15. Driving while intoxicated 16. Major driving violations (reckless driving, speeding, no license, etc.) 17. Are you presently awaiting charges, trial, or sentence? 0-No 1-Yes 18. How many days in the past 30 have you engaged in illegal activities for profit? FOR QUESTIONS 19 & 20 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 19. How serious do you feel your present legal problems are? (Exclude civil problems) Page 4 of 7
20. How important to you now is counseling or referral for these legal problems? FAMILY/SOCIAL RELATIONSHIPS 1. Marital Status: 1-Married 4-Separated 2-Remarried 5-Divorced 3-Widowed 6-Never Married 2. Are you satisfied with this situation? 0-No 1-Indifferent 2-Yes 3. Usual living arrangements (past 6 mos.): 1-With sexual partner and children 2-With sexual partner alone 3-With children alone 4-With parents 5-With family 6-With friends 7-Alone 8-Controlled environment 9-No stable arrangements Directions for 4-12: Place "0" in relative category where the answer is clearly no for all relatives in the category; "1" where the answer is clearly yes for any relative within the category; "X" where the answer is uncertain or "I don=t know" and "N" where there never was a relative from that category. Page 5 of 7
Have you had significant periods in which you have experienced serious problems getting along with: 0=No 1=Yes Past 30 Days 4. Mother 5. Father 6. Brothers/Sisters 7. Sexual Partner/Spouse 8. Children 9. Other Significant family: 10. Close Friends 11. Neighbors 12. Co-Workers 13. How many days in the past 30 have you had serious conflicts: A. With your family? B. With other people? (Excluding family) FOR QUESTIONS 14 & 17 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: How troubled or bothered have you been in the past 30 days by these: 14. Family problems 15. Social problems How important to you now is treatment or counseling for these: 16. Family problems 17. Social problems Page 6 of 7
PSYCHIATRIC STATUS 1. How many times have you been treated for any psychological or emotional problems in the last 6 months? In a hospital As an outpatient or private patient Have you had a significant period, (that was not a direct result of drug/alcohol use), in which you have: 0=No 1=Yes Past 30 Days 2. Experienced serious depression 3. Experienced serious anxiety or tension 4. Experienced hallucinations 5. Experienced trouble understanding, concentrating or remembering 6. Experienced trouble controlling violent behavior 7. Experienced serious thoughts of suicide 8. Attempted suicide 9. Been prescribed medication for any psychological/emotional problem 10. How many days in the past 30 have you experienced these psychological or emotional problems? FOR QUESTIONS 11 AND 12 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 11. How much have you been troubled or bothered by these psychological or emotional problems in the past 30 days? 12. How important to you now is treatment for these psychological problems? Page 7 of 7
Instructions ADDICTION SEVERITY INDEX-Fifth Edition FOLLOW-UP VERSION 1. Leave No Blanks - Where appropriate code items: X=question not answered N=question not applicable Use only one character per item. Severity Ratings The severity ratings are interviewer estimates of the patient's need for additional treatment in each area. The scales range from 0 (no treatment necessary) to 9 (treatment needed to intervene in lifethreatening situation). Each rating is based upon the patient's history of problem symptoms, present condition and subjective assessment of her/his treatment needs in a given area. For a detailed description of severity ratings' derivation procedures and conventions, see manual. Subject Rating Scale 0 - Not at all 1 - Slightly 2 - Moderately 3 - Considerably 4 - Extremely GENERAL INFORMATION 1. Have you been in a controlled environment since the last interview? 1-No 2-Jail 3-Alcohol or Drug Treatment 4-Medical Treatment 5-Psychiatric Treatment 6-Other 2. How many days? MEDICAL STATUS 1. How many times have you been hospitalized for medical problems since the last interview? (Include o.d.'s, d.t.'s. Exclude detox.) 2. Are you taking any prescribed medication on a regular basis for a physical problem? 1-No 2-Yes 3. Do you receive a pension for a physical disability? (Exclude psychiatric disability.) 1-No 2-Yes; Specify: Source. McLellan, A. T., Parikh, G., Bragg, A., Cacciola, J., Fureman, B., & Incmikofki, R. (1990). Addiction Severity Index administration manual. Philadelphia, PA: Penn-VA Center for Studies of Addiction. ASIOFU Revised 7/19/96 Page 1 of 9
4. How many days have you experienced medical problems since the last interview? FOR QUESTIONS 5 AND 6 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 5. How troubled or bothered have you been by these medical problems since the last interview? 6. How important to you now is treatment for these medical problems? INTERVIEWER SEVERITY RATING 7. How would you rate the subject's need for medical treatment? CONFIDENCE RATINGS Is the above information significantly distorted by: 8. Subject's misrepresentation? 0-No 1-Yes 9. Subject's inability to understand? 0-No 1-Yes EMPLOYMENT/SUPPORT STATUS 1. Education since the last interview MOS. 2. Training or technical education since the last interview MOS. 4. Do you have a valid driver's license? 0-No 1-Yes 5. Have you had an automobile since the last interview? (Answer No if no valid driver's license.) 0-No 1-Yes 6. Usual (or last) occupation since the last interview. Specify in detail: 7. Does someone contribute to your support in any way? 0-No 1-Yes 8. (ONLY IF ITEM 7 IS YES) Does this constitute the majority of your support? 0-No 1-Yes 9. How many days were you paid for working since the last interview? (Include "under the table" work.) ASIOFU Revised 7/19/96 Page 2 of 9
How much money did you receive from the following sources since the last interview? 10. Employment (net income) 11. Unemployment compensation 12. DPA 13. Pension, benefits, or social security 14. Mate, family, or friends (money for personal expenses) 15. Illegal 16. How many people depend on you for the majority of their food, shelter, etc.? 17. How many days have you experienced employment problems since the last interview? FOR QUESTIONS 18 & 19 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 18. How troubled or bothered have you been by these employment problems since the last interview? 19. How important to you now is counseling for these employment problems? INTERVIEWER SEVERITY RATING 20. How would you rate the subject's need for employment counseling? CONFIDENCE RATINGS Is the above information significantly distorted by: 21. Subject's misrepresentation? 0-No 1-Yes 22. Subject's inability to understand? 0-No 1-Yes DRUG/ALCOHOL USE Since last interview Rt of adm. 1 Alcohol-any use at all 2. Alcohol-to intoxication 3. Heroin 4. Methadone 5. Other opiates/analgesics 6. Barbiturates 7. Other sed/hyp/tranq. 8. Cocaine ASIOFU Revised 7/19/96 Page 3 of 9
9. Amphetamines 10. Cannabis 11. Hallucinogens 12. Inhalants 13. Steroids 14. Tobacco 15. More than one substance per day (Incl. alcohol) Route of Administration: 1=Oral, 2=Nasal, 3=Smoking, 4=Non-IV injection, 5=IV injection 16. How many times since the last interview have you: Had alcohol d.t.'s Overdosed on drugs 17. How many times since the last interview have you been treated for: Alcohol Abuse Drug Abuse 18. How many of these were detox only? Alcohol Drug 19. How much would you say you spent since the last interview on: Alcohol Drugs 20. How many days have you been treated in an outpatient setting for alcohol or drugs since the last interview (Include NA, AA)? 21. How many days since the last interview have you experienced: Alcohol Problems Drug Problems FOR QUESTIONS 22 & 23 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 22. How troubled or bothered have you been since the last interview by these: Alcohol Problems Drug Problems 23. How important to you now is treatment for these: Alcohol Problems Drug Problems INTERVIEWER SEVERITY RATING 24. How would you rate the patient's need for treatment for: Alcohol Abuse Drug Abuse CONFIDENCE RATINGS Is the above information significantly distorted by: 25. Subject's misrepresentation? 0-No 1-Yes 26. Subject's inability to understand? 0-No 1-Yes ASIOFU Revised 7/19/96 Page 4 of 9
LEGAL STATUS 1. Are you on probation or parole? 0-No 1-Yes How many times since the last interview have you been arrested and charged with the following: 2. shoplifting/vandalism 3. parole/probation violations 4. drug charges 5. forgery 6. weapons offense 7. burglary, larceny, B & E 8. robbery 9. assault 10. arson 11. rape 12. homicide, manslaughter 13A. prostitution 13B. contempt of court 13C. other 14. How many of these charges resulted in convictions? How many times since the last interview have you been charged with the following: 15. Disorderly conduct, vagrancy, public intoxication 16. Driving while intoxicated 17. Major driving violations (reckless driving, speeding, no license, etc.) 18. How many months since the last interview were you incarcerated? MOS. 19. Are you presently awaiting charges, trial, or sentence? 0-No 1-Yes 20. What for? (If multiple charges, use most severe.) 21. How many days since the last interview were you detained or incarcerated? 22. How many days since the last interview have you engaged in illegal activities for profit? FOR QUESTIONS 23 AND 24 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: ASIOFU Revised 7/19/96 Page 5 of 9
23. How serious do you feel your present legal problems are? (Exclude civil problems) 24. How important to you now is counseling or referral for these legal problems? INTERVIEWER SEVERITY RATING 25. How would you rate the subject's need for legal services or counseling? CONFIDENCE RATINGS Is the above information significantly distorted by: 26. Subject's misrepresentation? 0-No 1-Yes 27. Subject's inability to understand? 0-No 1-Yes FAMILY/SOCIAL RELATIONSHIPS 1. Marital Status: 1-Married 4-Separated 2-Remarried 5-Divorced 3-Widowed 6-Never Married 2. Are you satisfied with this situation? 0-No 1-Indifferent 2-Yes 3. Usual living arrangements (since the last interview): 1-With sexual partner and children 2-With sexual partner alone 3-With children alone 4-With parents 5-With family 6-With friends 7-Alone 8-Controlled environment 9-No stable arrangements 4. Are you satisfied with these living arrangements? 0-No 1-Indifferent 2-Yes ASIOFU Revised 7/19/96 Page 6 of 9
Directions for 5-13: Place "0" in relative category where the answer is clearly no for all relatives in the category; "1" where the answer is clearly yes for any relative within the category; "X" where the answer is uncertain or "I don't know" and "N" where there never was a relative from that category. Have you had significant periods in which you have experienced serious problems getting along with: 0=No 1=Yes Since last interview 5. Mother 6. Father 7. Brothers/Sisters 8. Sexual Partner/Spouse 9. Children 10. Other Significant family: 11. Close Friends 12. Neighbors 13. Co-Workers 14. How many days since the last interview have you had serious conflicts: A. With your family? B. With other people? (Excluding family) FOR QUESTIONS 15 AND 16 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: How troubled or bothered have you been since the last interview by these: 15. Family problems 16. Social problems How important to you now is treatment or counseling for these: 17. Family problems 18. Social problems INTERVIEWER SEVERITY RATING 19. How would you rate the subject's need for family and/or social counseling? CONFIDENCE RATINGS Is the above information significantly distorted by: 20. Subject's misrepresentation? 0-No 1-Yes 21. Subject's inability to understand? 0-No 1-Yes ASIOFU Revised 7/19/96 Page 7 of 9
PSYCHIATRIC STATUS 1. How many times have you been treated for any psychological or emotional problems since the last interview? In a hospital As an outpatient or private patient 2. Do you receive a pension for a psychiatric disability? 0-No 1-Yes Have you had a significant period (that was not a direct result of drug/alcohol use), in which you have: 0=No 1=Yes Since last Interview 3. Experienced serious depression 4. Experienced serious anxiety or tension 5. Experienced hallucinations 6. Experienced trouble understanding, concentrating or remembering 7. Experienced trouble controlling violent behavior 8. Experienced serious thoughts of suicide 9. Attempted suicide 10. Been prescribed medication for any psychological/emotional problem 11. Experienced serious sexual dysfunction 12. Experienced serious eating problems 13. How many days since the last interview have you experienced these psychological or emotional problems? FOR QUESTIONS 14 AND 15 PLEASE ASK SUBJECT TO USE THE SUBJECT RATING SCALE: 14. How much have you been troubled or bothered by these psychological or emotional problems since the last interview? 15. How important to you now is treatment for these psychological problems? THE FOLLOWING ITEMS ARE TO BE COMPLETED BY THE INTERVIEWER: At the time of the interview, is subject: 16. Obviously depressed/withdrawn 0-No 1-Yes ASIOFU Revised 7/19/96 Page 8 of 9
17. Obviously hostile 0-No 1-Yes 18. Obviously anxious/nervous 0-No 1-Yes 19. Having trouble with reality testing, thought disorders, paranoid thinking 0-No 1-Yes 20. Having trouble comprehending, concentrating, remembering 0-No 1-Yes 21. Having suicidal thoughts 0-No 1-Yes INTERVIEWER SEVERITY RATING 22. How would you rate the subject's need for psychiatric/psychological treatment? CONFIDENCE RATINGS Is the above information significantly distorted by: 23. Subject's misrepresentation? 0-No 1-Yes 24. Subject's inability to understand? 0-No 1-Yes ASIOFU Revised 7/19/96 Page 9 of 9