Screening for 

Drug uSe in 

general MeDical 

SettingS 

Resource Guide 
This guide is designed to assist clinicians serving adult patients in screening for drug use. The NIDA 

Quick Screen was adapted from the single-question screen for drug use in primary care by Smith et 

al. 2010 (available at http://archinte.ama-assn.org/cgi/reprint/170/13/1155) and the National 

Institute on Alcohol Abuse and Alcoholism's Helping Patients Who Drink Too Much: A Clinician's 

Guide Updated 2005 Edition (available at http://pubs.niaaa.nih.gov/publications/Practitioner/

CliniciansGuide2005/clinicians_guide.htm). The NIDA-modified ASSIST was adapted from the 

World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test 

(ASSIST), Version 3.0, developed and published by WHO (available at http://www.who.int/

substance_abuse/activities/assist_v3_english.pdf). 

This pamphlet is in the public domain and may be reproduced.
1

Screening for Drug Use in General Medical 

Settings: A Resource Guide for Providers

Table of Contents

I. Introduction

II. Before You Begin Screening Patients

III. Screening Your Patients

- Step 1: Ask patient about past year drug use – the NIDA Quick Screen

- Step 2: Begin the NIDA-Modified ASSIST

- Step 3: Determine risk level 

IV. Conducting a Brief Intervention

- Step 4: Advise, Assess, Assist and Arrange

V. Appendices:

- Recommendations to Address Patient Resistance

- Sample Progress Notes

- Change Plan Worksheet

- Biological Specimen Testing

- Additional Resources
2

Introduction

This Resource Guide is intended to provide 

clinicians serving adult populations∗ in 

general medical settings with the screening 

tools and procedures necessary to conduct 

screening, brief intervention, and/or

treatment referral for patients who may 

have or be at risk of developing a substance 

use disorder. Screening and brief 

intervention provides an opportunity for 

clinicians to intervene early and potentially

enhance medical care by increasing 

awareness of the likely impact of substance 

use on a patient’s overall health.

Why screen for drug use (including 

tobacco, alcohol, illicit [i.e., illegal], 

and nonmedical use of prescription 

drugs)? 

 Drug use (licit or illicit) is harmful and 

has many adverse consequences.

Multiple physical health, emotional, and 

interpersonal problems are associated 

with illicit drug use. Cardiovascular 

disease, stroke, cancer, HIV/AIDS, 

anxiety, depression, sleep problems, as 

well as financial difficulties and legal, 

work, and family problems can all result 

from or be exacerbated by drug abuse.1

 The use of illicit drugs is more common 

than you might think. In 2010, an 

estimated 22.6 million Americans aged 

12 or older (~8.9 percent of the 

population) were current illicit drug

users, which means they had used an 

illicit drug during the month prior to the 

survey. About 1 in 5 Americans aged 

18−25 used illicit drugs in the past 

month.2

 Only a fraction of individuals who need 

specialty treatment for drug or alcohol

addiction actually receive it each year.

 ∗ This resource guide does not specifically address the 

unique considerations that must be taken into account 

when screening adolescents or pregnant women.

In 2010, of the 23.1 million persons aged 

12 or older who needed specialized 

treatment for a drug or alcohol problem, 

most—almost 21 million—did not 

receive it.

3 Routine screening for 

substance use disorders could alter this

statistic and get more people the help 

they need.

 Using screening and brief intervention 

procedures in general medical settings 

can make a difference in drug use 

behaviors. Research has demonstrated 

that screening and brief intervention can 

promote significant reductions in alcohol 

and tobacco use.

4,5,6 A growing body of 

literature also suggests benefits of 

screening and brief intervention for illicit

or nonmedical prescription drug use as 

well.

7,8

How do you screen and provide 

feedback? 

As a medical provider, you are an important 

figure in your patients’ lives. In a very short 

conversation, you have a wonderful 

opportunity to let your patients know if and 

how their drug use may be putting their 

health at risk.

The Five A’s of Intervention (Ask, Advise, 

Assess, Assist, Arrange) can be a useful 

framework for encouraging patients to quit 

smoking and may also be useful for 

screening and providing feedback related to 

other drug use.

ASK – Screening is the first A because it asks 

one or more questions related to drug use. 

ADVISE – The second A involves strong 

direct personal advice by the provider to the 

patient to make a change, if it is clinically 

indicated.

ASSESS – The third A refers to determining 

how willing a patient is to change his or her 

behavior after hearing the provider’s advice.
3

ASSIST – The fourth A refers to helping the 

patient make a change if he/she appears

ready.

ARRANGE – The final A is to refer the 

patient for further assessment and 

treatment, if appropriate, and to set up 

followup appointments.

If you are not already doing so, we encourage you to incorporate drug use screening and 

brief intervention into your practice. The remainder of this Resource Guide provides detailed 

information to begin screening for:

Alcohol 

 

 

 

 

 

Tobacco 

 

 

 

 

 

 

Nonmedical 

Prescription Drug Use 

 

 

 

 

 

Illicit Drugs 

 

 
4

Before you begin screening patients 

While most health care settings have 

established processes and procedures for 

patient screening of health conditions such 

as high blood pressure, cholesterol, breast 

or prostate cancer, etc., drug abuse 

screening in general medical settings

involves additional practical 

considerations:9,10

 Determine staffing roles, including who 

will administer the screening instrument;

discuss results with patients; and 

intervene and/or refer when necessary.

 Train designated staff to conduct 

screening, intervention, and referral.

 Decide how screening results will be 

used and develop a procedure for 

handling positive and negative results. 

Note: Screening is not a full assessment; 

refer patients for a full assessment if a 

problem is indicated by the screen or 

through discussion with the patient.

 Apply existing office procedures to 

screening practices, including patient 

documentation, consent procedures,

confidentiality and HIPAA procedures, 

storage of records, and patient flow.

 Obtain reimbursement information for 

your State. 

o In 2007, the Centers for Medicare 

and Medicaid Services (CMS) 

adopted new codes for alcohol and 

substance abuse assessment and 

intervention services in the 

Healthcare Common Procedure 

Coding System (HCPCS). 

o In January 2008, the American 

Medical Association (AMA) adopted 

Current Procedural Terminology 

(CPT) codes for screening and brief 

intervention, and new Medicare “G” 

codes became available that parallel 

the CPT codes (see

http://www.samhsa.gov/prevention/

SBIRT/coding.aspx for more 

information). 

 Establish relationships and linkages with 

external providers who will accept 

referrals for additional assessment 

and/or drug treatment. 

 Consider patient reading level when 

providing educational and support 

materials. Because it is often difficult to 

determine reading level, particularly in 

emergency room situations, consider 

using materials developed for an 8th

grade reading level. An important 

resource is NIDA’s easy-to-read website 

for adults with low literacy. This 

website, which contains information 

about drugs, addiction, recovery and 

treatment, is available at 

http://easyread.drugabuse.gov.

 Deal with severe, immediately lifethreatening medical consequences of 

substance abuse as you would any other 

medical emergency.

o If same-day substance abuse 

treatment assessment is not 

available, transfer patient to the 

emergency room or admit to the 

hospital. 

o Arrange alternative transportation 

for patients under the influence of 

drugs, alcohol, or medication that 

would impair their driving. For these 

patients, the brief intervention 

should focus on crisis management.
5

Screening Your Patients
6

Screening Your Patients:

Step 1: Ask about past year drug use

Step 2: Begin the full NIDA-Modified ASSIST 

Step 3: Determine risk level 

The NIDA Quick Screen

Step 1: ASK about past year drug use

The NIDA Quick Screen and NIDA-modified ASSIST are appropriate for patients age 18 or 

older. You may deliver it as an interview and record patient responses, or read the questions

aloud and have the patient fill out responses on a written questionnaire. It is recommended 

that the person administering the screening review the sample script to introduce the 

screening process. The script offers helpful language for introducing what can be a sensitive 

topic for patients. 

Introduce yourself and establish 

rapport. 

Before you begin the interview, please read 

the following to the patient:

Hi, I’m __________, nice to meet you. If it’s okay 

with you, I’d like to ask you a few questions that will help me give you better medical care. The 

questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances 

we’ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you 

have taken them for reasons or in doses other than prescribed. I’ll also ask you about illicit or illegal 

drug use––but only to better diagnose and treat you.

 If the patient declines screening, advise the patient that you respect that decision but 

would like to inform him/her about the potential harms of drug use.

Ask patients about past year drug use using the NIDA Quick Screen. 

 Without being judgmental or confrontational, ask the 

patient how many times, within the past year, has he or 

she used any of the substances listed on the NIDA Quick 

Screen (http://www.drugabuse.gov/nmassist/).

 If the patient says “Never” for all drugs in Quick Screen, 

reinforce abstinence. For example, you may say “It is 

really good to hear you aren’t using drugs. That is a very 

smart health choice.” Screening is complete. 

 If patient says “Never” to alcohol use, Advise patient to 

stay within these limits: 

For healthy men under the age of 65: No more than 4 

drinks per day AND no more than 14 drinks per 

week.

For healthy women under the age of 65 and not 

pregnant (and healthy men over the age of 65): No 

more than 3 drinks per day AND no more than 7 

drinks per week.

Reminder:

Patients should be advised 

of the limits of 

confidentiality and 

insurance coverage for 

conditions occurring under 

the influence of alcohol or 

illicit drugs (these vary by 

State and provider).

Reminder:

Many people don’t know 

what counts as a standard 

drink (e.g., 12 oz beer, 5 oz 

wine, 1.5 oz liquor). 

For information, please see 

http://pubs.niaaa.nih.gov/p

ublications/Practitioner/Cli

niciansGuide2005/clinician

s_guide13_p_mats.htm
7

 If patient answers indicate one or more days of heavy drinking, patient is an at-risk 

drinker. 

Please see NIAAA website “How to Help Patients Who Drink Too Much: A Clinical 

Approach”:

http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians

_guide.htm, for information on how to Assess, Advise, Assist, and Arrange help 

for at risk drinkers or patients with alcohol use disorders

 If patient answers indicate use of tobacco: Any current tobacco use places a patient at 

risk. Advise all tobacco users to quit. For more information on smoking cessation, 

please see “Helping Smokers Quit: A Guide for Clinicians” 

http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.htm

 If the patient says “Yes” for use of illegal or prescription drugs for nonmedical 

reasons proceed to Step 2 and begin the NIDA-Modified ASSIST.

Step 2: Begin the NIDA-Modified ASSIST 

(http://www.nida.nih.gov/nidamed/screening/nmassist.pdf).

Ask the patient about lifetime drug use. 

 If patient reports “No” to lifetime use of all drugs listed in Question 1, remind them 

that their responses to the NIDA Quick Screen indicate they have used an illegal or 

prescription drug for nonmedical reasons within the past year. Repeat Question 1. 

 If patient indicates that the drug used is not listed, please indicate “Yes” next to 

other and continue to Question 2.

 If a patient reports “Yes” to lifetime use of substances listed in Question 1, proceed to 

Question 2, which asks questions about use in the last three months.

 If patient reports “Never” to Question 2 (i.e., no use in the past three months), 

proceed to Question 6.

 If patient reports use of any drugs in the past three months, complete Questions 3-8.

Step 3: Determine risk level 

 

Score the NIDA-Modified ASSIST for illicit and nonmedical prescription drug 

use. 

 For each substance, add up the scores received for Questions 2–7. This is the 

Substance Involvement (SI) score. Do not include the results from either Step 1 (Quick 

Screen), Question 1 or Question 8 in your SI score. The patient will receive an SI score 

for each substance endorsed, not a cumulative score. Therefore, the patient’s risk 

level may differ from drug to drug. 

 Use the resultant SI score to identify patient’s risk level. If more than one substance 

is reported, focus intervention on the substance with the highest score.
8

Reminder:

Use clinical 

judgment if the 

patient reports use 

of multiple drugs 

but does not score 

highly on any of 

them (i.e., consider 

an intervention). 
9

Step 4: Brief Intervention

Review results with patient, then:

• Advise patient about drug use

• Assess readiness to quit

• Assist patient in making changes

• Arrange treatment or follow-up 

care

Reminders to improve patient rapport: 

• Avoid tone that the patient might think is 

judgmental or confrontational.

• Show an interest in what the patient’s life is like.

• Acknowledge the patient’s current view of 

his/her drug use.

• Signal to the patient that having mixed feelings 

about a drug use problem is normal.

• Highlight patient confidentiality (and its 

limitations).

Screen, then Intervene: Conducting a 

Brief Intervention

Step 4: Advise, Assess, Assist and Arrange

This brief intervention gives patients a chance to learn about their drug use—especially as it 

pertains to their health—from an objective third party with medical training. It relies on the 

premise that advice from an expert has been shown to promote change.

11,12

Begin by reviewing screening results with the patient. 

 Ask permission to have a short discussion 

about the screening results. 

 Report back the types and amounts of use 

reported (giving patients the NIDA-Modified 

ASSIST tally sheet may be helpful). 

o Allow the patient to correct 

omissions so you get the full picture 

of use. 

o Prompt the patient: “Tell me more 

about your use of drug X and Y” (for 

each drug the patient reported). 

 If the patient has used within the past 3 months, review other ASSIST responses.

ADVISE - Provide medical advice about the patient’s drug use.

 Explain that it is your role as 

his/her medical provider to 

convey health 

recommendations. 

 Recommend quitting before 

problems (or more problems) 

develop. Give specific medical 

reasons.

o Medically supervised 

detoxification may be 

necessary for discontinuing 

use of some drugs (e.g., benzodiazepines).

 When appropriate, educate patients on the 

following:

o Use of even small amounts of drugs, including 

alcohol or tobacco, may negatively impact 

health and performance (e.g., driving or 

operating machinery).

o Because drug intoxication can lead to impaired 

Reminder:

The screen is only one 

indicator of a patient’s 

potential drug use problem. It 

is not a substitute for clinical 

judgment, which you should 

use to determine when an 

intervention is warranted. 
10

judgment and risky behaviors, refer all sexually active patients for confidential 

testing for HIV and other sexually transmitted diseases or provide an onsite testing 

opportunity, if they do not know their status or have not been tested recently. 

Encourage all patients to practice safe sex.

o Refer all patients with past or current injection drug use (Question 8) for HIV and 

Hepatitis B/C testing if they have not been tested twice over a 6-month span 

following their last injection.

 Make referrals to evaluate suspected co-occurring conditions (e.g., psychiatric

consultation for depressed, inattentive, or anxious patients or pain specialist 

consultation for patients seeking narcotic prescriptions for chronic nonmalignant 

pain).

 Provide recommendations based on risk level:

Risk level Recommendation 

High risk A strong recommendation to change substance use is essential. Consider making a 

statement such as: “Based on the screening results, you are at high risk of having 

or developing a substance use disorder. It is medically in your best interest to 

stop your use of [insert specific drugs here]. I am concerned that if you do not 

make a change quickly, the consequences to your health and well-being may be 

serious.” Include a referral for additional assessment (the NIDA-Modified ASSIST 

provides a risk level, but not a diagnosis of abuse or dependence). Let the patient 

know that the assessment will determine whether they have a diagnosis of 

substance abuse or dependence and if substance abuse treatment is indicated. 

Whether to attend treatment will be the patient’s decision.

• Specific examples of harm for different problem drug categories may be 

helpful.

• Emphasize that there are many ways to change substance use behavior (e.g., 

community treatment programs, self-help groups, medications, etc.). 

• Emphasize that treatment is often on an outpatient basis and programs are 

often accommodating of concerns like maintaining employment, insurance 

reimbursement, child care, etc., depending on the patient’s concerns.

Moderate risk Consider beginning the discussion by saying, “Based on the screening results, you 

are at moderate risk of having or developing a substance use disorder. It is 

medically in your best interest to change your use of [insert specific drugs here].”

• Add information that is specific to the drugs the patient uses. 

• Express your concern about specific ways drugs might negatively impact your 

patient’s life (e.g., health, relationships, work, etc.).

• Emphasize that there are many ways to change substance use behavior (e.g., 

community treatment programs, self-help groups, medications, etc.). 
11

Lower risk Consider having a discussion about acceptable levels of use and the potential for 

future problems. You may begin the discussion by saying “Your screening results 

show you are unlikely to have a substance use disorder. However, people with 

any history of substance use can be at some risk of adverse consequences and

developing a disorder especially in times of stress or if they have just started to 

use recently. It is impossible to know in advance whether or not a person will 

become addicted. As your physician I encourage you to only use alcohol 

moderately and responsibly and to avoid using other substances.”

• Intervention duration may be minimal

• Use your clinical judgment based on the medical status of the patient and drug 

being used. For example, pregnant women,* youth, people with histories of 

substance use disorders, and others for whom any drug use could potentially 

pose a serious risk may benefit from a complete intervention regardless of 

apparent risk level.

ASSESS the patient’s readiness to quit.

 Have a conversation about whether the patient is ready to quit. For example, you 

might say something like, “Given what we’ve talked about, do you want to change 

your drug use?”

 If the patient is unwilling to quit, raise awareness about drugs as a health problem. 

Let patients who are not ready know that you will revisit the issue at future visits and 

have resources available when he/she decides to pursue making a change. 

 If the patient is ready to quit, reinforce current efforts and then assist patient in their 

efforts to make changes that will help them reduce and/or quit their drug use. 

ASSIST patient in making a change. 

 Jointly complete a progress note form (Appendix 2) with the patient to document the 

screening results and create a followup plan. 

 Help set concrete (and reasonable) goals for making a change (see Appendix 3: Change 

Plan Worksheet, for more information). 

o Ask interested patients to complete a change plan before they go home.

o Make a copy without their name or the name of your office on it, give it to them to 

take home, and tell them you will check in on their progress at the next visit.

o For patients who do not complete a change plan, schedule a second appointment 

to continue the discussion and to complete the change plan. You may provide a 

blank copy for them to take home and ask them to return with it, but some 

patients may need to start again with a fresh copy during their second 

appointment.

o For patients not interested in completing a change plan, encourage them to set a 

few brief change goals (e.g., cutting back, trying a self-help group); record the

goals to check progress at the next visit. 

 Prescribe medications for office-based treatment of tobacco, alcohol, or opiate 

addiction, as appropriate.

 * Providers should be aware that many States mandate reporting of drug use during pregnancy and that failure to 

do so may be a prosecutable offense. 
12

Offer continuing support at followup 

visits.

• Refer patients as appropriate

• Schedule follow-up

• Offer continuing support at follow-up

ARRANGE specialty assessment, drug treatment, followup visit.

• Refer patients as appropriate. 

 Because the screening does not 

provide a diagnosis of abuse or 

dependence, refer high-risk patients 

for a full assessment. For moderaterisk patients and low-risk patients with 

special concerns (e.g., pregnant 

women, past injection drug users), use clinical judgment to determine whether 

additional assessment is necessary. Use SAMHSA’s treatment locator (see Appendix 5, 

http://findtreatment.samhsa.gov/) or NIDA’s National Drug Abuse Treatment Clinical 

Trials Network List of Associated Community Treatment Programs (see Appendix 5, 

http://www.drugabuse.gov/ctn/) to locate assessment resources.

 If nearby treatment resources are not available, consider providing support group 

contact information and self-change materials, as well as counseling resources––

clergy or mental health referrals.

 Obtain a written information release to send the screening results to all providers who 

will receive referrals.

• Schedule a followup appointment within 1–2 weeks for moderate - and highrisk patients and low -risk patients in certain groups.

• Offer continuing support at followup visits. 

 Annual rescreening is indicated for patients who report any drug use at baseline (even 

with scores of 0−3) and for any other patients about whom you remain concerned. For 

moderate- and high-risk patients, rescreen at next appointment.

 At followup, make targeted recommendations to moderate-, high- and select lowerrisk patients accordingly:
13

Risk level Targeted Recommendations 

High risk Determine 

whether the 

patient 

followed 

through with 

the referral.

Offer 

additional 

brief 

intervention 

for patients 

who did not 

attend the 

referral.

Make 

additional 

referrals for 

patients who 

missed 

referral.

Obtain records 

of assessment 

and/or 

treatment for 

patients who 

attended 

referral and/or 

treatment.

Discuss ways 

to help 

support 

recommendations of 

referral 

source.

Moderate 

risk 

Determine 

whether the 

patient 

reduced or 

abstained 

from use.

For patients 

who did not 

make progress 

with change 

efforts, 

acknowledge 

change is hard, 

repeat brief 

intervention, 

and discuss 

additional 

ways to 

support the 

patients’

efforts.

For patients 

who have 

made changes, 

reinforce 

efforts and 

encourage 

additional 

goal-setting.

Follow up at 

subsequent 

visits.

Lower risk If the patient 

indicated that 

he/she wanted 

to make a 

change, ask 

what, if 

anything, the 

patient 

decided to do 

about 

substance use.

Encourage 

abstinence 

from tobacco 

and illicit 

drugs and 

advise low-risk 

alcohol users 

to remain 

within 

acceptable 

drinking levels.

On evidence of 

escalation of 

use, conduct 

brief 

intervention.
14

Appendix 1—Recommendations to Address 

Patient Resistance (may not be applicable in every case)

Patient Resistance Scenario Physician Response

Patient answers “no,” seemingly without 

considering it thoughtfully or is reluctant 

to give details.

• Gently probe with a question like: “Not even when you were 

in school?”

• Encourage discussion by saying “go on” or “tell me more.”

Patient is uncomfortable disclosing 

personal substance use on a form.

• Let the patient know you will follow up in person about the 

screening. 

• Reinforce that all information provided will be kept 

confidential when possible.

• If patient is still uncomfortable, skip screening but provide 

information about harms associated with drug use.

Patient appears ashamed or embarrassed 

about recommendations to change 

substance use behaviors.

• State that this is a health-related medical recommendation

and is not meant to judge or stigmatize them. 

• Remind the patient of your role—that physicians have a duty 

to share test results with their patients. 

At-risk patient appears ambivalent to the 

idea of changing his/her substance use 

behavior.

• Acknowledge the patient’s ambivalence and the fact that 

ambivalence is common.

• State your concern about specific ways that drugs may

negatively affect your patient’s health or personal life.

Patient becomes upset, argumentative. • Do not argue with the patient. Give the patient time to make 

a decision (unless the condition is life-threatening). 

• Discuss his/her concerns and reflect them back (e.g., convey 

that you understand the patient’s claim that drugs make 

them feel better or that their peers use them).

Patient resists referral for additional 

assessment

• Explore concerns about the assessment.

• Emphasize that referral for an assessment may not mean 

entering substance abuse treatment—and that treatment, if 

recommended, likely will include different options.

Patient cites barriers to attending the 

referral appointment.

• Problemsolve about barriers and offer support, such as 

reminder calls, assistance arranging transportation, and child

care.

Patient resists the idea of going into 

formal substance abuse treatment.

• Clearly state that you are not insisting on formal treatment.

• Explain that treatment is often easier than quitting “cold 

turkey” and that stopping the use of certain drugs (e.g., 

alcohol, benzodiazepines) without medical supervision can 

be dangerous.

In followup visits, patient shows no 

progress with change efforts.

• Acknowledge that change is difficult.

• Repeat the brief intervention and discuss other ways to 

support the patient’s efforts. 

• Make additional referrals for patients who did not attend the 

referral.
15

Level of risk associated with different 

Substance Involvement Score ranges for 

illicit or nonmedical prescription drug use

0–3 Low Risk

4–26 Moderate Risk

27+ High Risk

Appendix 2—Sample Progress Note

DATE:

Time with patient (min):

Performed by: Primary Physician:

SCREENING: Circle each substance used and 

record Substance Involvement Score

Substance List: 

a. cannabis________________ f. Inhalants________ 

b. cocaine_________________g. Sedatives________

c. prescription h. prescription 

amphetamines_____________ opioids_________

d. street opioids____________i. hallucinogens_____

e. methamphetamine_________________________ 

j. Other_____________________________________

Past 3 months (list

substances):______________________

________________________________

Biological Test Results:_______________

IF ALCOHOL USE (circle below): 

PLAN:

Discussed screening results with patient (check if completed)______

Provided a Brief Intervention (check if completed)______

How ready is patient to change behavior? Unwilling_____ Tentative______ Ready_______

Change Plan completed? Yes ____ (attach) No ____ N/A ____

Change Plan appointment? Yes ____ No___ N/A ____

REFERRAL STATUS: 

Refer for further assessment?__________ Refused?____________ N/A _______

Refer to detox? _____________________ Refused?____________ N/A _______

FOLLOWUP PLANS:

Date of next appointment to check progress_____________

Or, for low-risk patients, rescreen on next RTC___________, or one year (if negative). 

 

Provider Signature:________________________Patient Signature:_____________________ 
16

Appendix 3—Change Plan Worksheet 

See http://www.hhs.gov/opa/familylife/tech_assistance/resources/ami-materials.pdf for 

more information and examples. 

The changes I want to make (or continue making) are: 

The reasons why I want to make these changes are: 

The steps I plan to take in changing are: 

The ways other people can help me are: 

I will know that my plan is working if: 

Some things that could interfere with my plan are: 

What I will do if the plan isn’t working: 

As my doctor, you can help me keep these changes by:
17

Appendix 4—Biological Specimen Testing

 

Introduction to Biological Testing 

Urine drug testing is the most common toxicological test of body fluid samples in general 

medical settings, but you do not need to have a biological testing program to implement a 

drug screening program. The purpose of a biological testing program is to:

 Confirm the presence of a drug or the use of multiple drugs.

 Augment screening and followup conversations (i.e., biological testing should not 

preclude screening). 

Users of biological tests should be aware that: 

 Biological tests have different windows of detection. For example:

o A positive urine or saliva screen for cocaine and/or heroin likely indicates very 

recent use (past few days/past week), whereas one for marijuana could detect 

marijuana use one month or more in the past. 

o It is almost impossible to determine the time of use from hair samples.

 Not all biological screens test for all commonly abused drugs (e.g., MDMA, 

methadone, fentanyl, and other synthetic opioids are not included in many drug 

screens, and these tests must be ordered separately).

 Biological tests examine a sample with a drug concentration at a specific cutoff level 

(see 

http://workplace.samhsa.gov/DrugTesting/pdf/2010GuidelinesAnalytesCutoffs.pdf). 

Therefore, a negative result does not mean drugs have not been used, and a positive 

result may at times reflect consumption of other substances (such as hemp or poppy 

products). 

 If tampering is a concern, specimens should be monitored for temperature or 

adulterants; and programs should implement and follow accurate chain-of-custody 

procedures.

Feedback for biological screening results: 

 Present results in a matter-of-fact way in conjunction with NIDA-Modified ASSIST 

feedback.

 Re-administer the test if the patient believes the result showed a false positive.

 If the second biological test results are positive, categorize the patient as high risk and 

offer a brief intervention and referral for additional assessment and possible 

treatment. 
18

Appendix 5—Additional Resources

Screening Information: 

Henry-Edwards, S.; Humeniuk, R.; Ali, R.; Poznyak, V.; and Monteiro, M. The Alcohol, Smoking and 

Substance Involvement Screening Test (ASSIST): Guidelines for Use in Primary Care. Geneva, 

Switzerland: World Health Organization (WHO), 2008. Available at 

http://www.who.int/substance_abuse/activities/en/Draft_The_ASSIST_Guidelines.pdf.

Center for Substance Abuse Treatment. Alcohol Screening and Brief Intervention (SBI) for Trauma 

Patients: Committee on Trauma Quick Guide. Substance Abuse and Mental Health Services 

Administration, DHHS Publication No. (SMA) 07-4266. Washington, DC: U.S. Government Printing 

Office, 2007. Available at http://www.samhsa.gov/csatdisasterrecovery/featuredReports/01-

alcohol%20SBI%20for%20Trauma%20Patients.pdf.

Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care 

Clinicians. Treatment Improvement Protocol (TIP) Series, Number 24. Substance Abuse and Mental 

Health Services Administration, DHHS Publication No. (SMA) 97–3139. Washington, DC: U.S. 

Government Printing Office, 1997. Available at 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.45293 .

Brief Intervention Instruction and Additional Information: 

World Health Organization. Brief Intervention for Substance Use: A Manual for Use in Primary Care—

http://www.who.int/substance_abuse/activities/en/Draft_Brief_Intervention_for_Substance_Use.pdf.

National Institute on Alcohol Abuse and Alcoholism’s Helping Patients Who 

Drink Too Much: A Clinician’s Guide:

http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm.

SAMHSA’s Treatment Facility Locator: 

 Searchable directory of drug and alcohol treatment programs around the country that treat drug 

abuse, alcoholism, and alcohol abuse problems.

 Simply enter an address into the “quick search” feature, and you will see a list of substance abuse 

treatment facilities closest to the address. Additional instructions available at 

http://findtreatment.samhsa.gov/images/loc_short.pdf.

NIDA’s National Drug Abuse Treatment Clinical Trials Network List of Associated 

Community Treatment Programs:

http://www.drugabuse.gov/CTN/ctps.html.

Resources on Certification in Office-Based Buprenorphine: 

http://buprenorphine.samhsa.gov/howto.html.
19

 1 Devlin, R.J,, and Henry, J.A. Clinical review: Major consequences of illicit drug consumption. Crit Care. 

12(1):202, 2008. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2374627/pdf/cc6166.pdf. 2 Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on 

Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H38A, HHS Publication No. SMA 10-4856Findings). Rockville, MD. Available at :

http://www.oas.samhsa.gov/NSDUH/2k10NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.1A

http://www.oas.samhsa.gov/NSDUH/2k10NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.1B 3 Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on 

Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H38A, HHS Publication No. SMA 10-4856Findings). Rockville, MD. Available at :

http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm

4 Madras, B.K. ; Compton, W.M. ; Avula, D. ; Stegbauer, T.; Stein, J.B.; and Clark, W.H. Screening, brief 

interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: 

Comparison at intake and 6 months later. Drug and Alcohol Depend 99: 280-95, 2009. Available at: 

http://www.ncbi.nlm.nih.gov/pubmed/18929451

5 Bernstein, J.; Bernstein, E.; Tassiopoulos, K.; Heeren, T.; Levenson, S.; and Hingson, R. Brief motivational 

intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend 77(1):49–59, 2005. Available 

at 

http://www.ncbi.nlm.nih.gov/pubmed/15607841?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_

ResultsPanel.Pubmed_RVDocSum. 6 Humeniuk, R.; Dennington, V.; Ali, R.; and WHO ASSIST Phase III Study Group. The Effectiveness of a Brief 

Intervention for Illicit Drugs Linked to the ASSIST Screening Test in Primary Health Care Settings: A Technical 

Report of Phase III Findings of the WHO ASSIST Randomized Controlled Trial (Draft). Geneva, Switzerland, 

2008.

7 Babor, T.F.; McRee, B.G.; Kassebaum, P.A.; Grimaldi, P.L.; Ahmed, and K.;Bray, J.; Screening, brief 

intervention, and referral to treatment (SBIRT): toward a public health approach to the management of substance 

abuse. Substance Abuse. 28: 7-30, 2007. 8 Bernstein E, Edwards E, Dorman D, Heeren T, Bliss C and Bernstein J (2009). Screening and Brief Intervention 

to Reduce Marijuana Use Among Youth and Young Adults in a Pediatric Emergency Department. Acad Emerg 

Med 16: 1174-85. http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2009.00490.x/pdf 9 Center for Substance Abuse Treatment. Alcohol Screening and Brief Intervention (SBI) for Trauma Patients: 

Committee on Trauma Quick Guide, Substance Abuse and Mental Health Services Administration, DHHS 

Publication No. (SMA) 07-4266. Washington, DC: U.S. Government Printing Office, 2007. Available at 

http://www.samhsa.gov/csatdisasterrecovery/featuredReports/01-

alcohol%20SBI%20for%20Trauma%20Patients.pdf. 10 Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. 

Treatment Improvement Protocol (TIP) Series, No. 24. Substance Abuse and Mental Health Services 

Administration, DHHS Publication No. (SMA) 97–3139. Washington, DC: U.S. Government Printing Office, 

1997.

11 Rossi, P.; Di Lorenzo, C.; Faroni, J.; Cesarino, F.; and Nappi, G. Advice alone vs. Structured detoxification 

programmes for medication overuse headache: a prospective, randomized, open-label trial in transformed 

migraine patients with low medical needs. Cephalalgia. 26:1097–1105, 2006. 12 Vicens, C.; Fiol, F.; Llobera, J.; Cpoamor, F.; Mateu, C.; Alegret, S.; and Socias, I. Withdrawal from long-term 

benzodiazepine use: randomised trial in family practice. Br J Gen Pract 56:958–963, 2006.
U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES

National Institutes of Health