**1. Introduction**

Drug dependence has become a worldwide issue, and 31 million individuals are suffering from its negative effect [1]. Even worse, according to National Center for Health Statistics, 70,630 people were killed by drug-involved overdose in 2019 [2]. Moreover, yearly economy effect from illicit drug use is around 193 billion dollars in the United States [3]. It is important for drug dependences to receive interventions and treatments in time. Before receiving treatments, an effective screening or diagnosis assessment is necessary [4]. This review covers quantitative assessment methods for drug dependences and the corresponding treatments. It concluded more than 20 quantitative instruments that are put into three main categories, screening, severity diagnosis assessments, and treatment outcomes assessments. In addition, three different types of treatments, conventional treatments, emergency treatments, and novel treatment, are discussed.

## **2. Assessments**

### **2.1 Screening**

Screening instruments usually are brief and easy to conduct. They are considered as "flagging," because it's the fundament of further assessments or treatments [5, 6]. The screening instruments tend to diagnose the presence of potential drug use–related disorders in specific fields, such as psychopathology, physiology, and social ability. The answers of screening questions are usually "yes" or "no."

World Health Organization (WHO) developed The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) to screen and manage substance use and related issues. ASSIST has eight items to detect more than nine types of substance and scored 0.58–0.90 in test-retest reliability [7, 8]. Brown et al. proposed a twophase assessment, A Two-item Conjoint Screen for Alcohol and Other Drug Problems (TICS) for screening alcohol and drug disorders [9]. TICS has nine questions in phase 1 and five questions in phase 2. One item's answer is positive or negative, and the rest is never, rarely, sometimes, or often. TICS can screen around 80% drug dependences [9]. There is an approach, named Prenatal Substance Abuse Screen (5Ps), developed for prenatal females. The woman needs treatments if there is a "yes" in any of the five items. The overall accuracy of whether the woman needs treatments in 5Ps 0.776 [10].

Some screening techniques would contain more items to obtain more information. Skinner designed The Drug Abuse Screening Test (DAST), as a screening and treatment evaluation instrument for drug dependences [11]. It has 28 items, including background, drug use history, social stability, and psychology. The answer for each item is "yes" or "no" and scored 1 point for "yes," 0 for "no," except for items 4,5, and 7, for which a "no" response is given a score of "1." The cutoff point is 6 and 12. If the score of a patient is larger than 5 or larger than 11, they will be considered to be "might" or "definitely" have drug use disorders, respectively. The reliability of DAST was 0.86–0.91 in Internal Consistency Reliability [11]. DAST-10 and DAST-20 are two shortened versions of DAST and drug use disorders can be screened faster in these two [12]. Another one is CAGE-adapted to Include Drugs (CAGE-AID) [13]. CAGE is derived from four sections: Cut down, Annoyed, Guilty, and Eye-opener. The result indicates clinical significance, if two or greater questions are "yes" [13]. CAGE-AID had general good to excellent performance in different subjects [14, 15].

### **2.2 Severity diagnosis assessments**

Severity diagnosis assessments are to recognize the drug use–related disorders and estimate the level of the disorders. These assessments contain multiple items and have score for each item. Usually, the higher score represents the greater level of severity. Since 1970s, scientists have been studying on the assessments to diagnose

### *Quantitative Assessment Methods for the Severity of Drug Dependences… DOI: http://dx.doi.org/10.5772/intechopen.105582*

the severity of drug dependence. After 40 years, a number of addiction severity assessments have been developed. Addiction severity index (ASI) is one of the most famous ones. ASI was proposed by A. Thomas McLellan and his colleagues (1980). It is a structured clinical interview, focusing on several areas, including medical status, employment status, alcohol use, drug use, legal status, family relationships, social relationships, and psychological functioning. Higher score in ASI means the higher level of severity and greater indication of accepting treatment [16]. This instrument has been used more than 30 years and is considered as gold standard in measuring the severity of drug addiction. The reliability of ASI has been tested by different studies. For example, both McLellan et al. and Hodgins et al. claim that ASI is generally reliable, and most parts are good to excellent, in addiction severity assessment [17, 18]. Now, ASI has developed into sixth version, ASI-6. There are also several adjusted versions of ASI, such as The Addiction Severity Index, Lite version (ASI-Lite) [19] and Addiction Severity Index self-report form (ASI-SR) [20].

Psychiatric disorders are the main concerned part in drug dependence severity assessments. Some psychological disorders assessments are directly utilized in drug dependence. Diagnostic and Statistical Manual of Mental Disorders (DSM) is an assessment for psychiatric disorders. The first version of DSM, DSM-1, was designed by American Psychiatric Association in 1952, and then it has been adjusted into several versions, DSM-II, DSM-III, DSM-III-R, DSM-IV, DSM-IV-TR, and DSM-5 [21]. Although DSM series were developed to measure mental disorders, they were widely used in drug disorders [22] and as a benchmark or to compare with other drug-dependent severity assessments [23, 24]. DSM series are reliable in drug dependence severity assessments. For example, DSM-5 performed good to excellent in alcohol, opioid, cocaine, and cannabis use disorders [25]. DSM-III-R and DSM-IV had good to excellent reliability in most items in opiates, cannabis, and cocaine [26]. Composite International Diagnostic Interview Substance Abuse Module (CIDI-SAM) is derived from another famous interview psychiatric instrument CICI. CIDI-SAM can be utilized to test alcohol, tobacco, and nine classes of psychoactive drug disorders. The performance of CIDI-SAM was excellent in most target substance in the reliability test [23].

Based on DSM series, some other drug dependence scales have been developed. Substance Dependence Severity Scale (SDSS) is to test drug dependences' mental disorders, based on DSM-IV and ICD (mental health tests), as well as drug use history, such as frequency, recency, and amount of consumption in last 30 days [24]. It has 11 items to assess the severity and frequency, scored from 0 to 49, and higher score means higher severity level. SDSS had excellent performance in most items in alcohol, cocaine, heroin, and sedatives in test-retest. Semi-structured Assessment for Drug Dependence and Alcoholism (SSADDA) and The Chemical, Use, Abuse, and Dependence Scale (CUAD) are also DSM-based instruments. SSADDA has seven criteria to test a large range of indexes, including drug use history, social activities, and physical and psychological problems. SSADDA performed excellent in nicotine and opioid dependence, good in alcohol and cocaine, and fair in cannabis, sedatives, and stimulants [27]. CUAD relies heavily on the American Psychiatric Association's (1987) Diagnostic and DSM-III-R for substance use disorders [28, 29]. CUAD has maximum 80 items and has Substance Severity Score for each substance they used and Total Severity Score for all substance they used. Different from assessments mentioned above, CUAD has different score weight for different items. For example, for items 16 and 17, each item scores 4 points, but 3 points for item 15, if they are true. In test-retest reliability, CUAD performed with excellence [29].

Evaluating the severity of withdrawal symptoms is as important as assessing the severity when patients are using drugs. There are a group of assessments focusing on the severity of opiate dependence in withdrawal. Severity of Opiate Dependence Questionnaire (SODQ ) is a self-completion questionnaire that contains five sections for opiate dependence. It assesses opiate use, physical and affective symptoms in withdrawal, withdrawal-relief drug use, and rapidity of reinstatement of withdrawal symptoms after a period of abstinence. This assessment concerns more about the severity in withdrawal. The reliability was from 0.70 to 0.88 in Cronbach's alpha [30]. The Clinical Opiate Withdrawal Scale (COWS) is an 11-item clinician-administered instrument to assess opioid withdrawal severity [31]. COWS also has different score weights on different items. The possible maximum score is 48. The score represents the level of severity, 5–12 points: "mild," 13–24: "moderate," 25–36: "moderately severe," and more than 36: severe (more than 36, 33). The reliability of overall items in Cronbach's alpha is 0.78 [31]. There are several similar withdrawal scales focusing on opiates, such as The Himmelsbach Scale, The Opiate Withdrawal Scale, Subjective Opiate Withdrawal Scale, Objective Opiate Withdrawal Scale, Short Opiate Withdrawal Scale, and The Subjective Opiate Withdrawal Questionnaire [32–36]. Clinical Drug Use Scale (DUS) can assess the drug dependence severity in different stages. It is a self-report instrument with excellent reliability to scale abstinence, consumption without impairment, abuse, dependence, and dependence with institutionalization [37, 38].

Some instruments tend to use a large number of questions to obtain detailed information from drug dependences and some tend to use a small number of items to diagnose patients' severity as soon as possible. Similar to CUAD, 80 items, Substance Abuse Outcomes Module (SAOM) is a 113-item self-report scale. It covers patient characteristic, patient outcomes, and process of care. This assessment takes 20 minutes on average [39]. On the other hand, The Severity of Dependence Scale (SDS), Leeds Dependence Questionnaire (LDQ ), SDSS, Drug use disorder (DUD), and COWS have much fewer items. SDS has five items to measure the level of drug dependence, mainly focusing on psychological components [40]. (LDQ ) has 10 self-completion items, which are sensitive to severity change over time in opiate and alcohol dependences [41]. In both SDS and LDQ, each of the items can be scored from 0 to 3 and higher score represents higher level of drug dependence [40, 41]. DUD is a self-report measurement to assess drug use and dependence criteria for marijuana, cocaine, and painkiller. It tried to minimize the subjects' bias while designing [42]. The number of items does not represent the reliability. No matter large number items assessments, CUAD and SAOM or small number items SDS, LDQ, DUD, and COWS, both had good to excellent performance in reliability test, details in **Table 1**.

### **2.3 Treatment outcomes assessments**

Evaluating drug use–related disorders during treatment is crucial and treatments can be according to this. The assessments mentioned in severity diagnosis assessments can also be utilized during treatment. However, here are some methods that have been designed for it. SAOM, The Substance Abuse Treatment Scale (SATS), Australian Treatment Outcomes Profile (ATOP), Treatment Outcomes Profile (TOP) are focusing on the treatment outcomes in drug dependences. SATS measures the treatment progress for drug dependences. SATS and TOP monitor and assess patients with eight scales and 38 items, respectively [43, 44]. TOP covers more fields including substance use, health risk behavior, offending, and health and social functioning. In reliability

*Quantitative Assessment Methods for the Severity of Drug Dependences… DOI: http://dx.doi.org/10.5772/intechopen.105582*



*\*the reliability test is test-retest, if there is no indication; the coefficient is larger than 0.75, the reliability is excellent, 0.6–0.74 is good and 0.4–0.59 is fair. a one section might contain more than one item.*
