Instrument Abuse

Instrument abuse, instrument misuse, and instrument addiction seem to be ailments in the field of substance use disorders both in the research and clinical domains. As used here, instrument abuse is forcing instruments into uses for which they were not intended. Instrument misuse is using an instrument inappropriately. Instrument addiction consists of persistently recommending or using instruments, which no longer should be used.

Let’s start with instrument addiction. This is a syndrome consistently found in publications sponsored by federal agencies, such as NIAA, NIDA, and SAMHSA. Their TIPS (Treatment Improvement Protocol) and TAPs (Technical Assistance Publication) consistently list outdated screens and other assessment instruments while omitting more recent instruments with empirical evidence of utility. They seem to keep listing the same limited number of instruments over and over again.

One example of this is the MAST (Michigan Alcohol Screening Test), which I use in training as an example of how NOT to construct a screen. First, the MAST consists of more than 20 questions, which is way too long for an efficient addiction screen. We have found that shorter screens are often more accurate than long ones. Second, some of the questions cover very severe or late stage issues, such as delirium tremens and cirrhosis. The final point is that graduates of the school of social work at the University of Minnesota score positive on the MAST. A requirement for a required course is (or used to be) to attend an open AA meeting. One MAST question concerns whether one has attended an AA meeting and if so one scores positive. The question does not specify if one attended the meeting due to concerns about one’s own drinking.

Instrument misuse is simply using the wrong instrument for a given purpose. This typically involves using a screen and making decisions on the basis of the screen instead of using a comprehensive diagnostic interview or tool. Sometimes the reverse is seen where an extensive evaluation is used where a screen would be sufficient. Using a screen for substance use disorders at intake to a treatment program is from the Department of Redundancy Department. The person has been screened – determined to be at risk for a substance use disorder – by the very fact that the individual is presenting for an intake. At that point a diagnostic assessment and treatment planning workup are appropriate. In the case of first time DUI/DWI offenders, the initial evaluation might be to determine whether or not a referral to a treatment program is indicated. Research has documented that half of such offenders are not likely to have a substance use disorder. In such a situation, a screen or triage assessment, rather than a full workup, may be most efficient.

Finally, we have instrument abuse where an instrument is used or mandated for a function it is not designed to perform. The classic example of this is the ASI (Addiction Severity Index). This was designed as a treatment outcome evaluation tool – initially for chronic VA patients. The ASI provides essentially no diagnostic information or treatment planning guidelines based on the DSM-5 or ASAM Criteria respectively. Rather, it is designed to determine if certain measures have improved during the course of treatment or after completion of treatment. Measures of vocational functioning and medical care utilization can indicate treatment impacts, but are not necessarily essential for intake.

There are many valid, useful public domain and proprietary screening and assessment instruments available. Some are interchangeable in that any one of several options might be appropriate for a given task. Problems arise when inappropriate applications are either implemented, or worse mandated.

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