Application of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) instrument: an integrative review

ABSTRACT

Objective

To systematize the knowledge and the learning of how the instrument Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) has been applied.

Method

Integrative review, performed from May to July 2014, searching the databases Latin American and Caribbean Health Science Literature (LILACS), Medical Literature Analysis and Retrieval System Online (Medline), PubMed and Scientific Electronic Library Online (SciELO), as well as in the search system of the Portal of Journals of the Coordination for the Improvement of Higher Education Personnel (CAPES). We selected 26 articles.

Results

ASSIST focused on helping the identification and classification of psychoactive substances use, and it has proved to be important in screening the involvement with alcohol and other drugs, and effectiveness in primary health care.

Conclusion

It was confirmed as an instrument to be used in Health Care.

Health evaluation; Substance abuse detection; Street drugs

RESUMO

Objetivo

Objetivou-se sistematizar o conhecimento e a aprendizagem de como é a aplicação do instrumento Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

Método

Revisão integrativa, realizada entre maio e julho do ano de 2014, nas bases de dados Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Medical Literature Analysis and Retrieval System Online (Medline), PubMed e Scientific Electronic Library Online (SciELO), assim como no sistema de busca do Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Foram selecionados 26 artigos. Resultados: O ASSIST concentrou-se no auxílio da identificação e classificação do uso de substância psicoativa, tendo se revelado importante no rastreamento do envolvimento com o álcool e outras drogas, e efetivo no nível primário à saúde. Conclusão: Confirmou-se como instrumento a ser usado na Atenção à Saúde.

Avaliação em saúde; Detecção do abuso de substâncias; Drogas ilícitas

RESUMEN

Objetivo

El objetivo fue sistematizar el conocimiento y el aprendizaje sobre la actual aplicación del instrumento Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

Método

Revisión integradora, llevada a cabo entre mayo y julio de 2014, con búsqueda en las bases de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS), Medical Literature Analysis and Retrieval System Online (Medline), PubMed y Scientific Electronic Library Online (SciELO), así como en el sistema de búsqueda del Sitio de Periódicos de la Coordinación de Perfeccionamiento del Personal de Nivel Superior (CAPES). Se seleccionaron 26 artículos. Resultados: El ASSIST se concentró en la ayuda de identificación y clasificación del uso de sustancias psicoactivas, u ha demostrado ser importante en el seguimiento del participación con el alcohol y otras drogas, y eficaz en nivel primario de salud. Conclusión: Se confirmó como una herramienta para utilización en la Atención a la Salud.

Evaluación en salud; Detección de abuso de substancias; Drogas ilícitas

INTRODUCTION

Increased numbers on the use and abuse of alcohol and other drugs in the world and in Brazil set up a complex situation, involving a number of social, economic, cultural and health problems(¹-²). In this context, about 2 billion people worldwide use alcohol, with approximately 2.5 million deaths due to its consumption, and is estimated that about 250 million people have used illicit drugs at least once a year, being the cause of death in one out of every 10 adults(³).

The substances considered in this study as drugs covers intoxicants, medicines, stimulants, sedatives and hallucinogens(⁴). Another assumption is that the abuse of these substances is characterized as a serious public health problem, and its importance rely on the development and commitment of the Primary Care (PC) for the screening of alcohol use and other drugs, in the construction of community health promotion(⁵).

It is observed, therefore, the importance of the improvement of care practices to the person and family under the use and abuse of alcohol and other drugs, so that we can identify the direct relationship between early detection and effective treatment of drug addiction(⁶-⁸). In the early detection process, it is suggested the use of a screening tool, which is valid, reliable, and easy to apply(⁹).

In this light, the screening tests of alcohol, smoking and other substances use recommended by the World Health Organization (WHO) is the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), validated in Brazil in 2004 and oriented for use in PC. Its psychometric properties identify the use of psychoactive substances and the problems associated with the first contact with the subject(⁹).

ASSIST measures the level of dependence and contains eight questions, with the first seven regarding the use and problems related smoking, alcohol, marijuana, cocaine, stimulants, inhalants, hypnotics/sedatives, opiates and hallucinogens; the last question relates to drug injection(⁹). Scores lower than 3 (or 10 for alcohol) identify that the person is at low risk for substance use related problems; mean score of 4 (or 11 for alcohol) and 26 are indicative of harmful or problematic substance use; score above 27 for any substance suggests that the person is at high risk of addiction(⁷).

Similarly, the use of an instrument, such as ASSIST, allows healthcare professionals to perform mechanisms for active search for problems resulting from the abuse of alcohol, smoking and other drugs, as well as to recommend an intervention, according to the score obtained. This may corroborate in the improved care for people and families who experience this issue(¹⁰-¹¹).

This study aimed to review the knowledge on the application of ASSIST, so that researchers or professionals who use it are more familiar with its application and feel security in this research instrument. In this sense, the objective was to systematize the knowledge and learning as how the implementation of ASSIST instrument has been applied to screen the use and abuse of alcohol, smoking and other drugs.

METHODOLOGY

For the preparation of the study, we chose to use the integrative review of the literature (IRL). This is a research method that aims at analyzing scientific publications, allowing the systematization of knowledge of a particular topic. It comprises six stages: topic identification, hypothesis elaboration or research guiding question; establishment of inclusion and exclusion criteria for the studies; definition of the information to be extracted from the selected studies; assessment of the included studies; interpretation of results and presentation of the review(¹²). We considered as guiding principle the suggestions of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), which consisted of several items indicating the progress to be adopted by the reviewers, maintaining the quality of the results in the construction of knowledge(¹³).

Considering that ASSIST is an instrument used for early detection of alcohol, smoking and other substances problems, we elaborated the following research guiding question: How do researchers and health professionals apply ASSIST instrument in their studies, considering its orientation to screen alcohol, smoking and other substances problems, and its intervention in the assisted population?

The research was conducted from May to July in 2014. Thus, three independent researchers conducted the collection of data in combination with the search terms for each database. The following controlled descriptors were used: “health evaluation”; “Substance abuse detection”; and “street drugs”. The following uncontrolled descriptors were used: “Alcohol, Smoking and Substance Involvement Screening” and “ASSIST”.

With regard to the descriptors used for the elaboration of the IRL combination between them, “Alcohol, Smoking and Substance Involvement Screening”, showed greater number of studies, noting that the meaning of ASSIST acronym is an uncontrolled descriptor, followed by the combination of the descriptors “Health evaluation” AND “Alcohol, Smoking and Substance Involvement Screening”, and to add to the discussion, we used the descriptors: “street drugs” and “disorder related to substance use”

We selected the following databases to perform the IRL: Latin American and Caribbean Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (Medline), PubMed and Scientific Electronic Library Online (SciELO) employing their own search system. We also used the search system of the Journal Portal of the Higher Education Personnel Improvement Coordination (CAPES).

The inclusion criteria were: full-texts manuscripts and original available online in English, Spanish or Portuguese languages, published between the years 1997 to 2014, since the start of the ASSIST development occurred in 1997(⁵). The full-texts were able to address the implementation and possible interventions suggested and/or carried out by researchers who used ASSIST instrument in their studies. We excluded the studies of theoretical reflection, update and review, as presented in figure 1.

Figure 1
– Data collection flow chart for integrative review about the application and/or validation of the instrument Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in alcohol, smoking and other drugs users

Data analysis was performed through translation and reading of studies. The extracted information was transcribed for the validated instrument by Ursi(¹⁴), which enabled the organization of the studies, which were described in boxes created in Microsoft Word® 2007 in citation order throughout the text.

The results were shown descriptively, through the synthesis of the findings in two boxes. The first box presents the selected items according to the year of publication, reference number according to the citation order in the text, study type, level of evidence(¹⁵)and sample size. The second box presents the application of ASSIST, the objective of its application and the intervention researched, corroborated with the way of its use, the objective of the application and the interventions.

To define the levels of evidence, the studies were evaluated to determine the reliability for the use of its results, contributing to conclusions that would provide current knowledge about the proposed topic(¹²). For this classification, we used the following proposal(¹⁵): Level I refers to results of a meta-analysis of randomized controlled clinical trials; Level II refers to studies of experimental design; Level III concerns quasi- experimental researches; Level IV comes from evidence of descriptive studies or a qualitative methodological approach; Level V refers to cases or experiences reports; Level VI corresponds to expert opinion or based on standards or legislation.

RESULTS

This IRL shows that 34.6%(⁵,⁷,¹¹,¹⁶-²¹) of the studies came from the PubMed database, followed by CAPES Journals with 26.9%(²,²¹-²⁶), SciELO with 19.2%(¹⁹,²⁴,²⁷-²⁹), Lilacs, with 15.4%(⁶,⁸-⁹,³⁰) and Medline, with 3.8%(¹⁰), 19 studies were duplicated in these databases. After selection, 26 studies were intended for analysis. In order to synthesize and integrate the findings of this IRL and highlight the contributions of ASSIST in the research about the use and abuse of alcohol, smoking and other drugs, a summary box was elaborated. The box below presents the included studies description that met the criteria of this IRL:

Box 1
– Synthesis of the included studies description about the application of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

Reference	Year	Source of the research	Study type	Level of evidence	Sample size
WHO ASSIST Working Group(2)	2002	National/international	Cross-sectional	IV	236 participants
Spear et al.(5)	2009	International	Exploratory study	IV	20 participants
Castro et al.(6)	2010	National	Cross-sectional	IV	167 smokers
Parhami et al.(7)	2012	International	Cross-sectional	IV	100 patients
Castro et al.(8)	2008	National	Cross-sectional	IV	123 smokers
Henrique et al.(9)	2004	National	Cross-sectional	IV	147 patients
Jorge et al.(10)	2012	National	Cross-sectional	IV	891 adolescents
Costa et al.(11)	2013	National	Cross-sectional	VI	239 individuals
Andrade et al.(16)	2012	National	Cross-sectional	IV	12.721 university students
Denering e Spear(17)	2012	International	Retrospective with pre/post moments	V	453 university students
Khan et al.(18)	2012	International	Cross-sectional	IV	100 elderlies
Rubio Valladolid et al.(19)	2014	International	Cross-sectional	IV	485 patients
Prendergast e Cartier(20)	2013	International	Clinical trial	III	800 people
Merchant et al.(21)	2014	International	Randomized	II	395 participants
Humeniuk et al.(22)	2007	National/international	Cross-sectional	IV	1.047 participants
McNeely et al.(23)	2014	International	Cross-sectional	IV	101 participants
Eisenberg e Woodruff(24)	2013	International	Randomized	II	700 street drug users
Saitz et al.(25)	2014	International	Randomized	II	528 participants
Ali et al.(26)	2013	International	Accuracy	IV	2082 adults
Lopez et al.(27)	2012	National	Cross-sectional	IV	1848 individuals
Rodrigues et al.(28)	2012	National	Cross-sectional	IV	1.621 young
Peuker et al.(29)	2010	National	Cross-sectional	IV	40 individuals
Bertanha e Netto(30)	2012	National	Descriptive	VI	217 patients
Newcombe et al.(31)	2005	International	Case study	V	150 participants
Tockus e Gonçalves(32)	2008	International	Cross-sectional	IV	209 students
Oliveira et al.(33)	2014	National	Cross-sectional	IV	936 adolescents

• Source: Research data, 2014.

Considering the objective of the ASSIST application, we developed a synthesis of research results, presenting the professionals who have applied the instrument and the health interventions used, from the score obtained with the ASSIST. Below, we present the synthesis box:

Box 2
– Synthesis of the application of research interventions in the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

Reference	Year	How is ASSIST instrument applied?	Objective	Intervention
WHO ASSIST Working Group(2)	2002	Individually, in the form of data collection	To assess the applicability of the ASSIST test-retest in different places and cultures	No intervention was noticed
Spear et al.(5)	2009	Individually, in the form of data collection	To document the implementation of ASSIST in a university counseling center	Counseling, screening administered by the campus health center and brief clinical interventions
Castro et al.(6)	2010	Individually in the form of data collection, along with other instruments	To assess the use of psychoactive substances and correlates it with smoking	It suggests that, in the treatment of smoking, subgroups of smokers should be identified with specific characteristics
Parhami et al.(7)	2012	Individually in the form of data collection, along with other instruments	To assess the use of light substances in the initial evaluation of patients	It is suggested that interventions are made in accordance with the score for use in primary care contexts
Castro et al.(8)	2008	Individually in the form of data collection, along with other instruments	To assess the use of alcohol and psychoactive substance	To promote a brief intervention for smokers and users of other psychoactive substances
Henrique et al.(9)	2004	Individually in the form of data collection, along with other instruments	To facilitate the interpretation and the possibility of being used by health professionals from diverse background trainings	Guidance to seek treatment in specialized services
Jorge et al.(10)	2012	Individually, using the self-report form, along with other instruments	To collect information on the consumption of alcohol and street drugs	Because it is a cross-sectional study, it did not allow the establishment of a cause and effect relationship
Costa et al.(11)	2013	Individually, in the form of data collection, with another instrument	Screening problems with different levels of substances in general	Related to the comparison of the results of SCARED and ASSIST, the authors reported the contribution in the prevention of individuals at risk with problematic alcohol use
Andrade et al.(16)	2012	Individually, using the self-report form, along with another instrument	To assess the use of psychoactive drugs	Intervention referrals were not perceived
Denering e Spear(17)	2012	Individually, using the self-report form, along with other instruments	To reduce consumption and raise awareness among students about the hazards of the use and abuse of alcohol and other drugs	Awareness of the harms associated with substance abuse
Khan et al.(18)	2012	Individually, in the form of data collection, along with other instruments	To assess psychometric properties of the ASSIST	They suggested that the French version of ASSIST could be used as part of a more general approach to public health
Rubio Valladolid et al.(19)	2014	Individually, in the form of data collection, along with other instruments	To identify levels of problems with substance abuse	It is suggested to make use of the test as part of public health
Prendergast e Cartier(20)	2013	Individually, in the form of data collection, along with another instrument	To assess the psychometric properties of the French version of ASSIST	Screening, brief intervention according to individual level of risk, and referral for treatment
Merchant et al.(21)	2014	Individually, in the form of data collection, along with another instrument	To assess smoking, alcohol and other drugs use in the last 3 months	Brief intervention assessed, there was no report of changes
Humeniuk et al.(22)	2007	Individually, in the form of data collection, along with other instruments	To assess the use of drugs in large scale of substance use	Public health approach with programs for substance abuse in Primary Care
McNeely et al.(23)	2014	Individually, in the form of data collection and administered by computer, touch-screen tablet with headphones	To verify the level of risk for drug use	No intervention was noticed
Eisenberg e Woodruff(24)	2013	Individually, in the form of data collection, along with other instruments	To assess the use and abuse of alcohol, smoking and other drugs	They received a brief intervention related to the use of drugs according to their level of risk
Saitz et al.(25)	2014	Individually, in the form of data collection, along with other instruments	To specify which are the drugs used and their scores	It was found that an applied brief intervention was not effective
Ali et al.(26)	2013	Individually, in the form of data collection, along with other instruments	To assess the use of alcohol, smoking and other drugs	To encourage further external validation using new samples in other cultural contexts
Lopez et al.(27)	2012	Individually, in the form of data collection, along with other instruments	To assess the use of drugs	Intervention referrals were not perceived
Rodrigues et al.(28)	2012	Individually, in the form of data collection, along with other instruments	Evaluate the use of psychoactive substances	Intervention referrals were not perceived
Peuker et al.(29)	2010	Individually, in the form of data collection, along with another instrument	To detect the abuse of psychoactive substances	Only descriptive associations were found
Bertanha e Netto(30)	2012	Individually, in the form of data collection, along with other instruments	Detection of abuse and addiction of alcohol and other psychoactive substances	Brief intervention performed for smoking, alcohol, marijuana, cocaine, crack and amphetamines
Newcombe et al.(31)	2005	Individually, in the form of data collection, along with other instruments	Quantitative evaluation construction and discriminated validity of ASSIST	Brief intervention according to the ASSIST score
Tockus e Gonçalves(32)	2008	Individually, in the online form available on the university website, along with another instrument	To detect drug use	Implementation of secondary prevention program in population was suggested
Oliveira et al.(33)	2014	Individually, using the self-report form, along with another instrument	To determine the use of inhalants and marijuana	It is suggested that public policies for prevention should be strengthened and focused on adolescents

• Source: Research data, 2014.

The analysis of the included studies highlighted the year 2012, with 30.8%(⁷,¹⁰,¹⁶-¹⁸,²⁷,²⁸,³⁰) of the publications. According to inclusion and exclusion criteria adopted for this IRL, the years 1997 to 2000, 2001, 2003, 2005, 2006 and 2011 had no included studies.

The application was conducted in heterogeneous groups with adult prevalence (73.1%)(²,⁵-⁹,¹¹,¹⁷,²⁰-²⁷,³⁰-³³), followed by young students (15.4%)(¹⁶,¹⁷,¹⁹,²⁸), adolescents (7.7%)(¹⁰,²⁹) and elderly (3.8%)(¹⁷). Regarding the level of evidence, the higher prevalence studies referred to those with level IV, that is, cross-sectional studies, which corresponded to 69.2% of the sample(²,⁴-¹⁰,¹⁶,¹⁸-²⁰,²³-²⁴,²⁷-²⁹,³³).

Many professionals proceeded to the implementation of ASSIST and among them, we highlight different health professionals (53.8%)(⁵,⁷,¹⁰,¹⁷-¹⁹,²¹,²³-²⁶,²⁸,³¹-³²), followed by trained individuals named as interviewers (34.6%)(²,⁶,⁸,¹¹,²⁰,²²,²⁷,³³), and researchers (authors), which corresponded to 11,5%(⁹,¹⁶,²⁵).

Regarding the database which the studies were obtained, 34.6%(⁵,⁷,¹¹,¹⁶-¹⁸,²¹,²³,²⁶) were from PubMed, followed by the CAPES Journal Portal with 26.9%(²,²⁰,²²,²⁵,³¹-³³), SciELO with 19.2%(¹⁹,²⁴,²⁷-²⁹), LILACS with 15.4%(⁶,⁸,⁹,³⁰) and Medline with 3,8%(¹⁰).

With regard to place of publication, 50%(⁵,⁷,¹⁷-²¹,²³,²⁵,²⁶,³¹-³³) of the studies were international, 42.3%(⁶,⁸,⁹,¹⁰,¹¹,¹⁶,²⁴,²⁷-³⁰) were national and 7.7%(²,²²) were considered as both.

DISCUSSION

The analysis of the studies identified a higher number of publications in 2012. It is possible that this occurred due to the interest of researchers in the implementation of ASSIST, since it was a little known instrument(⁵), besides being useful in the classification of alcohol, smoking and other drugs abuse.

In the included studies, some point out that the ASSIST was used to assess and classify the frequency and the prevalence of drug use and abuse(¹⁶,¹⁸,²⁴,²⁹); others have chosen to use the instrument as a way to quantify and know the drugs used by adolescents and young adults(⁸,¹⁰,¹⁷,¹⁹) in order to identify the pattern of consumption as well as substances of greatest demand, with repercussions in health condition, social and family life(³⁴) and thus verify the need for interventions(⁷). Studies support that the ASSIST is used as an instrument that brings information about the epidemiology of use and abuse of legal and illegal substances, in addition to measuring the severity of consumption(³⁵).

Some studies have shown that the questionnaire can be self-applied(³⁶), highlighting its use in adolescents and youth, in addition to the application resource through electronic means (online), which provides ease for research implementation(¹⁰,¹⁶, ¹⁹,²⁰,²⁹). The efficiency regarding the instrument of this study is notable for measuring the use and abuse of smoking, alcohol and other drugs with possible actions for certain scores(⁷,¹⁹,²³,²⁹). With regard to interventions, these are guided by test score fluctuating among brief intervention levels in intensive care, in order to prevent morbidities and chronic condition installation due to the abuse of psychoactive substances(³⁷).

The implementation perspective of preventive practices in PC focusing on drug users, requires the training of professionals to carry out brief interventions and enforcement of the instrument that addresses this reality of consumption: the ASSIST(³⁸). The test proposed brief intervention to patients who made use of substances such as alcohol, smoking and other drugs(⁹). Among the studies found, 38.5%(⁵,⁷-⁹,¹⁷,²¹,²⁵,²⁶,³⁰,³²) applied some sort of brief intervention, which consisted of counseling and orientation, which supports the development of autonomy in people.

From the studies analyzed, 23.1% did not apply any interventions(²,¹⁰,¹⁶,²⁰,²⁷-²⁸); 23.1% suggested that the instrument should be implemented in the PC for screening of drug use and abuse, and preventing the increase of consumption(⁶,⁸,¹⁸-¹⁹,²²,²⁹) and therefore before the classification criteria of the test, it is possible to assess the risk attributed to the stage of development for each substance(³⁹-⁴⁰). The other studies used the ASSIST score for comparison with results from other instruments(¹¹), incentive for validation by demonstrating the psychometric properties to detect problems associated with drugs(⁴¹-⁴²) and application of the ASSIST in PC(³³), and for drug use identification in order to develop long-term interventions(¹⁷).

Studies have shown that the ASSIST was used concurrently with other questionnaires, especially: Alcohol Use Disorders Identification Test (AUDIT), MINI International Neuropsychiatric Interview (MINI-Plus), sociodemographic questionnaire, Fagerstrom and Tolerance Questionnaires (RTQ), Addiction Severity Index (ASI), Drug Abuse Screening Test (DAST), Severity of Dependence Scale (SDS) and Maudsely Addiction Profile (MAP)(⁶,⁸-¹⁰,¹⁷-²⁵,²⁸-³¹,³³). We highlight the fact that the AUDIT questionnaire is an international instrument developed by WHO, and it was the most used by included studies and the development of ASSIST was based on its improvement(²,⁹).

Although the ASSIST has been an important instrument in screening alcohol and other drugs problems, and effective in primary care, especially in family health, it was found that in only 3.8%(⁷) of the assessed studies, the application of the instrument was performed by nurses; in the other studies, with the collaboration of other professionals, both in health care and/or trained individuals. In research on prevention practices developed by nurses in the PC, the authors found, through interviews, suggestive signs of a negligent behavior in relation to the topic of care for people in drug use and abuse, in the context of these professionals, above all due to the lack of knowledge on how to deal with this people and how to use screening instruments for this condition.(⁴³).

CONCLUSION

In this IRL, the synthesis of results facilitated the understanding of evidence, namely, accelerated knowledge transfer into practice. The studies were multi-professional and, mostly, of individual application, allowing professionals to measure and assess the risk of substance abuse. The effectiveness Evidence of ASSIST focused on identification and classification of the use of alcohol, smoking and other drugs in different populations and age groups.

The highest prevalence rates were in the studies that made use of the ASSIST as an identifier of alcohol, smoking and other drugs problems, testing variables and hypothesis, and few studies used its score as a guide for interventional practices. This finding indicates that the ASSIST still requires research application to explore its full potential.

Thus, limitations from the study consisted in the fact that the descriptors “ASSIST” and “Alcohol, Smoking and Substance Involvement Screening” are not controlled, which reinforces the need for this IRL and explains the difficulty in finding scientific studies that describes the application, effectiveness and intervention, as well as being a recent instrument, being developed in 1997 and the Brazilian validation in 2004.

It is suggested that future studies focus on the application of brief interventions and work in multidisciplinary teams to help changes in behavior or even knowledge and community adherence.

This IRL pointed out the need to conduct research exploring the indication of intervention, according to its score, exactly because this is a complex study object that requires attention and assertive practices in community health.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  16 Jan 2015
• Accepted
  03 Dec 2015