U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

www.samhsa.gov 

CSAT’s 

Knowledge Application Program 

KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for 

Primary Care Clinicians 

KAP Keys

For Clinicians
 

Based on TIP 24 

A Guide to Substance 

Abuse Services for Primary 

Care Clinicians 
KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for Primary Care 

Clinicians 

Introduction 

These KAP Keys were developed to accompany the Treatment 

Improvement Protocol (TIP) Series published by the Center for 

Substance Abuse Treatment (CSAT), Substance Abuse and 

Mental Health Services Administration. These KAP Keys are 

based entirely on TIP 24 and are designed to meet the needs 

of the busy clinician for concise, easily accessed "how-to" information. 

For more information on the topics in these KAP Keys, readers 

are referred to TIP 24. 

Other Treatment Improvement Protocols (TIPs) 

that are relevant to these KAP Keys: 

TIP 3, Screening and Assessment of Alcohol- and Other Drug 

Abusing Adolescents (1994) BKD108 

TIP 31, Screening and Assessing Adolescents for Substance 

Use Disorders (1999) BKD306 

TIP 34, Brief Interventions and Brief Therapies for Substance 

Abuse (1999) BKD342 

TIP 35, Enhancing Motivation for Change in Substance Abuse 

Treatment (1999) BKD342 
1 Interview Approaches Based on the Patient's 

Readiness for Behavioral Change 

KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for Primary Care 

Clinicians 

Precontemplation

• Express concern about the patient and substance use 

• State nonjudgmentally that substance abuse is a problem 

• Consider a trial of abstinence to clarify the issue 

• Suggest bringing a family member to an appointment 

• Explore the patient's perception of a substance use problem 

• Emphasize the importance of seeing the patient again 

Contemplation

• Elicit positive and negative aspects of substance use 

• Ask about positive and negative aspects of past periods of 

abstinence 

• Summarize the patient's comments on substance use and 

abstinence 

• Make explicit discrepancies between values and action 

• Consider a trial of abstinence 

Determination 

• Acknowledge the significance of the decision to seek treatment 

• Support self-efficacy 

• Affirm patient's ability to successfully seek treatment 

• Help the patient decide on appropriate, achievable action 

• Caution that the road ahead is tough but very important 

• Explain that relapse should not disrupt the patient-clinician 

relationship 

Action 

• Be a source of encouragement and support 

• Acknowledge the uncomfortable aspects of withdrawal 

• Reinforce the importance of remaining in recovery 

Maintenance 

• Anticipate difficulties as a means of relapse prevention 

• Recognize the patient's struggle 

• Support the patient's resolve 

• Reiterate that relapse should not disrupt the medical care 

approach 

Relapse

• Explore what can be learned from the relapse 

• Express concern and even disappointment about relapse 

• Emphasize positive aspects of the effort to seek care 

• Support patient's self-efficacy so that recovery seems 

achievable 
KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for Primary Care 

Clinicians 

Michigan Alcoholism Screening Test 

(MAST) 

2 

POINTS 

0. Do you enjoy a drink now and then? YES NO 

(2) 1. *Do you feel you are a normal drinker? 

(By normal we mean you drink less than or 

as much as most other people.) 

YES NO 

(2) 2. Have you ever awakened the morning 

after some drinking the night before and 

found that you could not remember a part 

of the evening? 

YES NO 

(1) 3. Does your wife, husband, a parent, or YES NO 

other near relative every worry or complain 

about your drinking? 

(2) 4. *Can you stop drinking without a struggle 

after one or two drinks? 

YES NO 

(1) 5. Do you ever feel guilty about your drinking? YES NO 

(2) 6. *Do friends or relatives think you are a 

normal drinker? 

YES NO 

(2) 7. *Are you able to stop drinking when you 

want to? 

YES NO 

(5) 8. Have you ever attended a meeting of 

Alcoholics Anonymous (AA)? 

YES NO 

(1) 9. Have you gotten into physical fights when 

drinking? 

YES NO 

(2) 10. Has your drinking ever created problems 

between you and your wife, husband, a 

parent, or other relative? 

YES NO 

(2) 11. Has your wife, husband (or other family 

member) ever gone to anyone for help 

about your drinking? 

YES NO 

(2) 12. Have you ever lost friends because of 

your drinking? 

YES NO 

(2) 13. Have you ever gotten into trouble at work 

or school because of drinking? 

YES NO 

(2) 14. Have you ever lost a job because of 

drinking? 

YES NO 

(2) 15.Have you ever neglected your obligations, YES NO 

your family, or your work for two more days 

in a row because you were drinking? 

(1) 16. Do you drink before noon fairly often? YES NO 

(2) 17. Have you ever been told you have liver 

trouble? Cirrhosis? 

YES NO 

Continued on back 
KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for Primary Care 

Clinicians 

POINTS 

(2)	 18. **After heavy drinking have you ever 

had Delirium Tremens (DTs) or severe 

shaking or heard voices or seen things 

that weren't really there? 

YES NO 

(5) 19. Have you ever gone to anyone for help 

about your drinking? 

YES NO 

(5)	 20. Have you ever been in a hospital 

because of drinking? 

YES NO 

(2)	 21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a 

general hospital where drinking was part 

of the problem that resulted in hospitalization? 

YES NO 

(2) 22. Have you ever been seen at a psychiatric 

or mental health clinic or gone to any doctor, social worker, or clergyman for help 

with any emotional problem where drinking 

was part of the problem? 

YES NO 

(2)	 23. ***Have you ever been arrested for YES NO 

drunk driving, driving while intoxicated, or 

driving under the influence of alcoholic 

beverages? If YES, how many times? _____ 

(3)	 24. Have you ever been arrested or taken 

into custody even for a few hours because 

of other drunk behavior? If YES, how many 

times? _____ 

YES NO 

*Alcoholic Response is negative 

**5 points for each Delirium Tremens 

*** 2 points for each arrest 

Scoring System: 

In general, five points or more would place the subject in alcoholic category. Four points would be suggestive of alcoholism, 

and three points or fewer would indicate the subject is not an 

alcoholic. 

Source: Selzer, M.L. The Michigan Alcoholism Screening Test: 

The quest for a new diagnostic instrument. American Journal 

of Psychiatry 127:1653-1658, 1971. 
KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for Primary Care 

Clinicians 

DSM-IV Diagnostic Criteria for 

Substance Abuse 

3 

The DSM-IV defines the diagnostic criteria for substance abuse 

as a maladaptive pattern of substance use leading to clinically 

significant impairment or distress, as manifested by one or 

more of the following occurring within a 12-month period: 

(1) Recurrent substance use resulting in a failure to fulfill 

major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance 

use; substance-related absences, suspensions, or expulsions 

from school; neglect of children or household). 

(2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a 

machine when impaired by substance use). 

(3) Recurrent substance-related legal problems (e.g., arrests 

for substance-related disorderly conduct). 

(4) Continued substance use despite having persistent or 

recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with 

spouse about consequences of intoxication, physical fights). 

DSM-IV Diagnostic Criteria for Substance Dependence 

Reprinted by permission from the Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition. Copyright 1994, 

American Psychiatric Association 

The DSM-IV defines the diagnostic criteria for substance 

dependence as a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in 

the same 12-month period: 

(1) Tolerance, as defined by either of the following: 

• The need for markedly increased amounts of the substance 

to achieve intoxication or desired effects. 

• Markedly diminished effect with continued use of the same 

amount of the substance. 

(2) Withdrawal, as manifested by either of the following: 

• The characteristic withdrawal syndrome for the substance. 

• The same (or closely related) substance is taken to relieve or 

avoid withdrawal symptoms. 

(3) Taking the substance often in larger amounts or over a 

longer period than was intended. 

(4) A persistent desire or unsuccessful efforts to cut down or 

control substance use. 

(5) Spending a great deal of time in activities necessary to 

obtain or use the substance or to recover from its effects 

(6) Giving it up social, occupational, or recreational activities 

Continued on back 
KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for Primary Care 

Clinicians 

because of substance abuse. 

(7) Continuing the substance use with the knowledge that it is 

causing or exacerbating a persistent or recurrent physical or 

psychological problem. 

Reprinted by permission from the Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition. Copyright 1994, 

American Psychiatric Association 
KAP KEYS Based on TIP 24 

A Guide to Substance Abuse Services for Primary Care 

Clinicians 

TWEAK Test 4 

To be used with pregnant women 

T Tolerance: How many drinks can you hold? 

W Have close friends or relatives worried or complained 

about your drinking in the past year? 

E Eye-opener: Do you sometimes take a drink in the 

morning when you first get up? 

A Amnesia: Has a friend or family member ever told you 

about things you said or did while you were drinking 

that you could not remember? 

K (C) Do you sometimes feel the need to cut down on 

your drinking? 

Scoring 

A 7-point scale is used to score the test. The "tolerance" question scores 2 points if a woman reports she can hold more 

than five drinks without falling asleep or passing out. A positive response to the "worry" question scores 2 points, and a 

positive response to the last three questions scores 1 point 

each. A total score of 2 or more indicates the woman is likely 

to be a risk drinker. 

Source: Russell, 1994. 
Ordering Information
 

TIP 24 

A Guide to Substance Abuse Services for
 

Primary Care Clinicians 

Easy Ways to Obtain Free Copies 

of All TIP Products 

1. Call SAMHSA's National Clearinghouse for Alcohol and 

Drug Information (NCADI) at 800-729-6686, 

TDD (hearing impaired) 800-487-4889. 

2. Visit CSAT's Website at www.csat.samhsa.gov 

Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of 

Communications, Substance Abuse and Mental Health 

Services Administration, U.S. Department of Health and 

Human Services. 

DHHS Publication No. (SMA) 01-3582 

Printed 2001