Clinical Support: Screening Issues

Ethical Issues

• The purpose of the SASSI is to help people with substance use disorders. To use the SASSI to discriminate against individuals, such as disqualifying job applicants or to deny public assistance, violates the purpose of the SASSI and is illegal under the Americans with Disabilities Act.
• No screening measure is 100% accurate, and specific clinical information is required to meet the accepted standards for a DSM-IV clinical diagnosis of a Substance Use Disorder. The SASSI can be a valuable tool for professionals making assessments when it is used properly and in conjunction with supplemental information.
• We encourage you to look over the following information regarding use of the SASSI in public assistance programs.

Always feel free to contact us at (800) 726-0526 should you have any questions regarding appropriate use of the SASSI.

Position Statement & Information Regarding Issues in Screening:  General Assistance Recipients
Increasingly, governmental agencies are requiring substance abuse assessment as part of the process of applying for general assistance. This is particularly true in "welfare to work" programs. Policy makers have come to recognize the value of providing adjunctive services such as substance abuse counseling and vocational counseling to those recipients of general assistance needing such services. Substance abuse treatment has a major beneficial effect on both the individual and society. However, public assistance is often made contingent on participation in the assessment and treatment process, which increases the risk for violations of ethical principles and applicants' rights.
The typical substance abuse screening procedure that is used in conjunction with applications for public assistance entails screening all qualified applicants for substance abuse. Those that are determined likely to be substance abusers are referred for a more comprehensive assessment. If they are then found to have a significant substance abuse problem, they are referred for treatment as part of the services they receive from the public assistance agency. Those who attend such treatment and comply with requirements continue to receive general assistance funds.

Our Position
The SASSI Institute supports substance abuse screening in the context of the provision of general assistance, as long as the process is beneficial for recipients and does not infringe on their dignity or abridge their rights. It is our mission to promote early identification of substance dependence that ultimately leads to appropriate intervention, treatment, and ongoing recovery. In so doing, we hope to lessen the personal suffering and societal costs that accompany substance abuse. We accomplish our mission by providing screening instruments for human service practitioners to use in developing screening programs in a broad range of human service settings, e.g., medical, counseling, criminal justice, vocational. We see our responsibility to develop valid and useful measures, to describe their reliability and validity, and to distribute them to qualified counselors.

Considering the SASSI in a Public Assistance Setting?
It is the responsibility of the counselors to establish policies regarding the use of screening instruments in their settings according to appropriate legal, ethical and professional guidelines. In response to continuing inquires from agencies considering use of the SASSI in general assistance programs, the Institute desires to provide information that counselors and agencies may find useful in consideration of adoption and application of the SASSI screening instruments and other assessment tools.

Optimal Diagnostic Procedure
The optimal diagnostic procedure for identifying substance use disorders is a comprehensive assessment conducted by a professional with relevant expertise that includes:

• One or more interviews, ideally with good rapport between client and professional.
• Consideration of other supportive information sources such as collateral contacts, test reports and legal history.

Screening instruments can be of value in reducing overall assessment costs and in reducing the number of people who receive unnecessary diagnostic evaluations.

Various Modes of Screening
No single measure is able to identify all substance abusers.

Body Fluids
Body fluid screens identify individuals who have psychoactive substances within their bodies at the time of the screening. They do not necessarily identify all people with substance-related disorders, especially alcoholics; and they misidentify some individuals who do not have a disorder but have a substance in their body at the time of the screening.

Questionnaires
Also, no paper and pencil instrument is 100% accurate in identifying substance abusers. Invariably, some individuals who are not substance abusers will be identified as abusers, and some abusers will be missed. For instance, the SASSI-3 for adults has a demonstrated overall accuracy rate of 94%, with  a 6% chance that the SASSI could mistakenly identify someone as having a high probability of having a substance use problem when they don’t and also a 6% chance that the SASSI-3 could potentially miss someone. 

SASSI for those in Recovery
Some people whose substance abuse is in remission and who do not need help in maintaining sobriety will often show as high probability of having a Substance Use Disorder.  The client would be better served by completing a questionnaire that assesses the client’s stability and level of vulnerability to relapse. The SASSI Institute is currently developing an instrument for this purpose, the Quality of Recovery Index (QRI). Please contact us if you’re interested in participating in research data collection using the provisional version.

Other Considerations
It is vital for a program to pilot its screening procedures to determine the proportion of individuals who do not have a substance abuse disorder who are identified as high risk by the measure and subsequently referred for more thorough assessment. It is also important to determine the proportion of substance disordered individuals referred for further assessment that are actually already in recovery and would not profit from help in maintaining their recovery. The recovery group becomes a focal point because of protection under the Americans with Disabilities Act - under which the inconvenience of further assessment could be construed as discriminatory. Also, public assistance agencies that institute a screening procedure may wish to be aware of the percentage of substance dependent clients who are missed by the screening tool and consequently are not identified as needing additional help.

The assessment and treatment-referral that is conducted subsequent to the screening is crucial in determining the ethical propriety of mandated substance abuse screening, assessment and treatment. Does the assessment constitute an unnecessary burden on applicants? Does it constitute an unnecessary burden on substance abusers that are in remission? Does it provide some benefit to substance abusers that are in remission? Is it free from conflicts of interest such as the assessment agent also serving as the treatment provider? Does it conform to state of the art standards?

It is also important to recognize that two programs appearing to be identical on paper can differ significantly in their impact. In one, applicants may be treated respectfully, be informed of the purpose of each step in the process, and referrals for further assessment and treatment conducted in such a way as to value the person and protect their dignity. In another program, the clients may not be treated with adequate respect, and referrals may be made in a critical rather than supportive fashion. These issues and others pertaining to the assessment, referral and treatment process are beyond the control of The SASSI Institute.

The SASSI Institute is pleased to provide information and/or assistance to human service providers, including public assistance agencies, to develop an assessment program that will further a shared mission of identification and treatment of substance abuse.