Addiction severity index

The ASI-5 survey contains a total of 164 items inquiring about the general background of the patients (n= 28), their conditions in the respective areas would be asked in the following according to the participants' preference on privacy recorded during the development of ASI: 1) Medical health (n= 11) 2) Employment/ support status (n= 24) 3 & 4) Drug/ alcohol use (n= 35) 5) Illegal activity/ legal status (n= 32) 6) Family/ social relationships (n= 38) and 7) Psychiatric health (n= 23).[1][4]

The general situations of each area would first be inquired, then patients are asked to rate in certain questions on their subjective feeling on the area. Next, interviewers would be able to estimate a score in the interviewer severity rating based on both objective and subjective information inquired. Lastly, a confidence rating would be given by the interviewers.

An interview using the ASI would be conducted with the patient alone and entirely confidential to safeguard the privacy of the patient.[1]

In the medical, alcohol, drug and psychiatric sections, there are the "Final Three" questions (the number of questions including, but not limited to 3) placed before the estimation of interviewer severity rating in which they are logically related. For instance, in the "medical health" area, question 6 inquires about the frequency of experiencing medical problems in the last 30 days, question 7 inquires about the frequency of being troubled by these medical problems (referring to question 6) and question 8 inquires about the importance of treatment for these medical problems (also referring to question 6). It could be seen that if question 6 is answered 0, questions 7 and 8 should also be answered 0. On the other hand, if question 6 is a non-zero positive number, questions 7 and 8 should also be answered with non-zero positive numbers.[5]

Confidence rating contains 2 questions confirming the full understanding of the interviewees which are rated by the interviewers. The items would ensure that there are no misrepresentations by the patients and they are able to understand all parts of the questions under certain sections.

Despite the feasibility of self-administration of the ASI with similar consistency as face-to-face interview,[6] the survey would be preferably conducted in an interactive interview privately as it ensures interviewees could understand all the questions by further repeating, paraphrasing as well as probing and as a gesture of politeness and support to patients.[1][5] The first interview which is done at admission would be estimated to complete within 45–75 minutes and the follow-up interview would be completed within 25–30 minutes.[1]  

Pharmaceutical companies using ASI in several pharmacovigilance studies to test for product abuse liability[1]

The original purpose of ASI was to serve as a standardized data collection instrument for clinical staff for the determination of the severity of the addiction of patients through objective and subjective information.[3] The estimated severity rating would guide the clinicians to determine the urgency of treatments. It was also designed for research staff to test for the efficacy of interventions by comparing the before and after results of the ASI using CSs.[1]

The popularity of ASI grew as other languages[7][8][9][10][11][12] of the ASI-5 was found to be equally reliable and valid. It could also be seen that the use of ASI was spread beyond the field of medicine and research. The expansion of populations that the ASI was used on besides the substance-dependent treatment population sees the increase of its versatility. Since 2000, the ASI has been used in sectors ranging from welfare to criminal justice to employment.[1] It was also used in conjunction with other indexes to have extensive reviews on not only the effectiveness but also the cost-effectiveness of novel treatment.[13] Lastly, the ASI is adopted in several pharmacovigilance studies by pharmaceutical companies to test for products abuse liability.[1][14]

The scoring system enables clinicians to determine the severity of the addiction of the patients which is defined as the need for treatment where there currently is none; or for an additional form or type of treatment where the patient is currently receiving some form of treatment,[5] instead of a deviation from optimum function.[3] It was exemplified that if a patient with extremely poor uncorrected vision but was adjusted with glasses, their pathological condition would be classified as severe yet using the definition used in ASI, their severity would be rated as minimal as they were well-adjusted with glasses for daily activities. In addition, it is of paramount importance to understand that the ratings do not indicate the potential benefits from treatments but depict the extent to which some forms of effective interventions are needed regardless of their existence and availability.[5]

In clinical practice, two scores would be derived for each section by reviewing the patient's situation in two time frames, including lifetime and past-30 days from the date of the interview. The scores from each section are independent of each other including the ISR and patient severity item. The ISR is determined by both objective information that are verifiable tests and patients' judgement of severity. Interviewers would gather all the objective information and a range of scores would be selected based on a 10-point system. The system would be listed below:[1][5][15]

Once a specific range is selected, the exact score would be determined based on the subjective information provided by the patient. It would be related to their subjective perceptions of their addictions only for the past 30 days before the initiation of the interview and they would be asked to grade by themselves based on a 5-point system. The scale would be listed below:[1][4][5][15]

Patients could leave the question blank if they are uncomfortable to answer.

Once the interviewers have selected the suitable range of severity rating, they would further derive the exact score based on the patients' subjective judgement. Should the patient choose higher scores in these specific questions, the higher point of the range would be selected.[1] If lower scores are rated by the patient, a middle or lower score of the range would be pinpointed by the interviewers.[1]

Despite the tested reliability and validity of the ISR and its ability to summarize patients' overall status in clinical admission, it has several drawbacks that made it not favourable for research purposes. Its subjective nature means that biases would easily be introduced during research analysis.[5] In addition, its reliability and validity only last when all the data is available and the interviews are done face to face which might not be in follow-ups.[1][5]

With reference to the shortcomings of ISR, composite scores (CSs) are derived specifically to evaluate changes over time and relativity to different population groups in research. CSs are used in a scoring system that could be calculated for each of the 7 aspects by combining items from specific questions inquiring about the past 30-day status with equal weighting.[5] In view of the possibility of large variations between answers (e.g.: patient rating scale of 0–4 and money earned), the composites would be calculated by dividing each item within a composite by its maximum value, then divide again by the total number of questions in the said composite.[16] Finally, summation of all the scores will generate a score between 0 and 1.

This is the cover page of the ASI composite score manual.[16]

An example has been depicted in the composite score manual.[16] In the medical sections, three questions are included in the composite score calculation:

A. How many days have you experienced medical problems in the last 30? (Maximum value = 30)

B. How troubled or bothered have you been by your medical problems in the past 30 days? (Maximum value = 4 (Patient's rating))

C. How important to you now is treatment for these medical problems? (Maximum value = 4 (Patient's rating))

If the answer recorded for the three questions were 15 days for A, a rating of 3/4 for B and a rating of 4/4 for C. The score would be calculated using the equation below:

${\displaystyle (15/30)/3+(3/4)/3+(4/4)/3=0.750}$

Although the CSs are a measure of problem severity, with high scores indicating higher severity, their intrinsic value would have little meaning and they could not be compared between different aspects probed. CSs are advised to be only used for measuring changes in various time-points of treatments or relative outcomes between groups.  

There are 2 possible scores that could be given to each of the 2 questions in the confidence rating (0= No and 1= Yes).[4] Factors ranging from unjustified contradiction of information to lack of confidence in answering, patients' misrepresentation to poor understanding of questions due to reasons including but not limited to language barrier and illiteracy all contribute to poor confidence rating.[5] Interviewers are encouraged to recognize and reconcile the aforementioned issues. But the interview would be terminated and rescheduled should the problems would not be resolved.