42 [ ASSIST | THE ALCOKOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST Appendix A The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST v3.1) Clinician Name Clinic Client 10 or Name Date Introduction (please read to client or adapt for local circumstances)" The following questions ask about your experience of using alcohol, tobacco products and other ‘drugs across your lifetime and in the past three months. These substances can be smoked, swal- lowed, snorted, inhaled or injected (show response card). Some ofthe substances listed may be prescribed by a doctor (ke amphetamines, sedatives, pain ‘mesications). For this interview, we will nt record medications that are used as prescribed by your doctor However if you have taken such medications for reasons ether than prescription, or taken them more frequenty or at higher doses than prescribed, please let me know. While we are also interested in knoving about your use of various illicit drugs, please be assured that information on such use wll be treated as strictly confidential Before asking questions, give ASSIST response card to client rare Pn nc Pty eres » Tobacco products (cigarettes, chewing tobacco, gars, etc) No Yes b Alcoholic beverages (beer, wine spirits, etc} No | Yes «Cannabis (arvana, pot, 91285, hash, ete) NoYes 6 Cocaine (coke, cack, etc) NoYes Amphetarrine-type stimulants speed, meth, ecstasy, etc) NoYes {Inhalants (nits, alu, petrol, paint thinner, etc.) NoYes 1 Sedativeso sleeping pls dlazepam, alprazolam, funitvazepar, midazolam, ete) NoYes fh Hallucinogen (50, ai, mshroons, rs, kta, ec) No Yes | Opioids (neroin, morphine, methadone, buprenorphine, codeine, et) No Yes | Other = speci NoYes * sas va. ste lun for seeing cn tig. Fr reste pepe ple eeu eon ASS.APPENDDGA | THE ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (ASSIST VB) | 8 Pelee have you used the substances you mentioned (first drug, second drug, etc)? 9 Tobacco products (cigarettes, chewing tobacco, cigas, etc) bb Alcoholic beverages feet, wine, sits ec.) © Cannabis (maruana, pot, grass, hash, etc) 1 Cocaine (coke, ack, et) © Ampretamine-type stimulant (speed, meth ecstasy, ete) ‘Inhalants (nitvtous, ale, petrol, paint thinner, etc.) 4 Sedatives or sleepin pls izepam, arazclom, funivazenam, 9 > ggg risazola ee} bh Hallucinogens (LSD, acid, mushrooms, trps,ketamine.etc) «0-23 | Opioids resin, morphine, methadone, buprenorphine codeneetc) 0 2 3 4 6 | other = speciy ol2 3)4i\6 Caen i iene often have you had a strong desire or urge to use er ecient 2 Tobacco products (clgaretes, chewing tobacco,cgarsete) 0 | 3 «S| bb Alcohol beverages bee, win, spits etc) o 3 4 5 6 «Cannabis (marjuana, po, grass, has, et) ofafa|sis © Cocaine (ake, rack, ee) o a)4 sis © Amphetamine stimulants pees, meth, ests, etc) ofajfa)sis “Inhalants (nites, sue, petrol, paint ninmer, et) o 3 4 5 6 1 Sedatives or sleeping pills dazepam, alprazolam, funitrazepam, midazolam, etc) by Hallacnagens (LSD, acid, mushrooms, trips, ketamine, ett.) o 3 4 5 6 | pices reron, morphine, methadone, buprenorphine, codeneetc) 0 | 3 4 5 | 6 | Other ~specity: a 2)4) 5s) 644 | ASSIST | THE ALCOHOL, sMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST ENR often has your use of (first drug, second drug, etc) led Pore ernie ea eure etd » Tobacco products (cigarettes, chewing tobacco, cgas, etc) ol/4 os 6\7 b Alcoholic beverages ibeer, wine spirits, etc) o|4a|s i 6|7 «Cannabis (marijuana, oot, 975s, hash, ete) of4i si 6|7 Cocaine (coke, crack, etc) ol4a|si6|7 © Amphetamine-ype stimulants (peed, meth, ecstasy, ete) ol4 si 6|7 {inhalants nitrous lue, petro, paint thinner, ete) ola|si|e6|7 a ee are bh Hallucinogens (15D, acid, mushrooms, trips, ketamine.etc) 0 8ST. | Opicasrercin, morohine, methadone, buprenorphine, codeine etc) 9 4 = SBT. | other ~specity olai|si6|7 Ce iene often have you failed to do what was normally expected of you because of your use of (first drug, Earn 2 Tobacco products ‘Ask questions 6&7 forall substances eve used (Le those endorsed in Qt). Aloha beverages fee, Wine sits ec) oj sis 7\8 «Cannabis arvana, pot grass, hash, ec.) os 6 718 4 Cocaine coke, rack, et) os 6 7/8 « Arphetamine-ype stindans peed, men stay et) os 6 718 {Inala irous, su, petrol paint hone et) os 6 7\8 4 Sedatives or leping pls iazepam, apazlom,furivazepam, gs gpg ricaclon, ec) Halucinegens (SB, acid, mushrooms, rps ketamine etc) OST | Onis eon moron metadon, buprenorstine aden etc) 9 «S$ § 7B | other~ spec. oj4is 6|7AAPPENDDK A | THE ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (ASSIST V2.) | 4S otentthan eae ie expressed concern about your use of (first drug, second drug, ete)? 2 Tobacco products (cigarettes, chewing tobacco, cigars, etc) o 6 3 b Alcoholic beverages (beer, wine soit, etc) 0 6/3 «Cannabis (mariana, pot, grass, hash, etc) o 6 3 6 Coceine (oke, cack ec.) 0 6/3 © Amphetamine-type stimulants (peed, meth ecstasy, ete) o 6 3 Inhalants (nitrous, lu, petro, paint thinner, etc) 0 6/3 9 Sedat sep area abrazlam Tuazoam, miszslam, olela by Hallucinogens (LSD, acid, mushrooms, tps, ketamine, etc.) 0 6 | 3 | Opioids theron, morhine, methadone, buprenorphine, codeine, etc.) o 6 3 |) Other = specify; o 6 | 3 Pa heat an drug, second drug, ete) but failed? 2 Tobacco products (cigarettes, chewing tobacco, agar, etc) b Alcoholic beverages (beer, wine spirits, etc) o 6 | 3 «Cannabis mariana, pot, gras, hash, etc) cra 6 Cocaine (coke, cack tc.) o 6 | 3 © Amphetamine-type stimulants (peed, meth ecstasy, etc) oj 6 | 3 4 Inhalants (nitrous lue, pet, paint thine, etc) o 6 | 3 9 Sada or seg cepa, fsa, Tuireepam midzlan, ae by Hallcinogens (Lb, acid, mushrooms, tps, Ketamine, et) o 6 | 3 | Opioids theroin, morphine, methadone, buprenorphine, codeine, etc.) oes] | other ~specity o 6 | 346 | ASSIST | THE ALCOHOL, sMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST het ae ener eed (Please tick the appropriate box) ue) Cents who have injected drugsin te last 3 months should be asked about ther pattern of injecting dating this period, to determine ther rk levels and the best couse of intervention, Pattern of injecting Intervention guidelines 4 days per month, on average, over the Brief intervention including the risks of last 3 months or less © injecting card More than 4 days per month, on Further assessment and more intensive average, over the last 3 months treatment How to calculate a specific substance involvement score. For each substance (labeled ‘ato ‘j) add up the scores received for questions 2 through 7 inclusive. Do not include the results from either Q1 or QB inthis score. For example, a score for cannabis ‘would be calculated as; Q2e + Q3c + Qde + Q5e + QEC+ Q7C.