Questionnaire

Description: 
Provides a downloadable patient satisfaction form. The survey assesses satisfaction with the health center and staff.
Source: 
SAMHSA
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Description: 
The ASI Self-Report Form asks questions about the following topics: your background and employment, your health and family relationships, your legal situation, and your drug and alcohol use.
Source: 
Center for Health Care Evaluation (CHCE)
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TICS

Description: 
The Two-Item Conjoint Screening (TICS) scale is a brief screening tool. It screens for current substance use or dependence in a primary care population.

The Two-Item Conjoint Screening (TICS) consists of 2 questions about substance use:

  1. In the last year, have you ever drunk or used drugs more than you meant to?
  2. Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?

Scoring: According to Brown et al., 1 positive response indicates a 45% likelihood of having a substance use disorder; 2 positive responses indicate a 75% chance. Sensitivity and specificity are both around 81%.

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DAST-10

Description: 
The Drug Abuse Screening Test, or DAST, is a self-administered test designed to provide a brief screening for drug abuse, followed by further assessment by a health care professional if necessary.

The 28-item, self-reporting Drug Abuse Screening Test (DAST) was created to screen for substance use in a clinical or treatment evaluation setting (Skinner 1982). A shorter version of the original DAST, the DAST-10, may be useful to screen for drug abuse in primary care.

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Patient Assessment Checklist

Description: 
Before starting office-based buprenorphine treatment, the following Patient Assessment Questions should be answered for each patient. Topics addressed in these questions include: Diagnosis, Medications, Drugs/Alcohol, Psychiatric and Medical Comorbidities, Psychosocial Issues, Treatment, Patient Management, and Resources. If multiple issues are identified, consider whether they can be managed in your practice or if the patient requires a higher level of case, i.e. an Opioid Treatment Program or higher level.

Diagnosis

Does the patient have a diagnosis of opioid use disorder?

  • Approximately how long has the patient been dependent?
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Description: 
This document provides a form for recording important information about prospective patients, including drug use history, treatment history, criminal history, health information, and more.
Source: 
Colleen LaBelle, RN/Boston Medical Center
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