Screening Issues

 

Ethical Issues:

• The purpose of the SASSI is to help people who have 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 a violation of the Americans with Disabilities Act.

• No screening measure is 100% accurate, and specific clinical information is required to meet the current American Psychiatric Association standards for a 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 proper use of the SASSI screening instruments.

 

Information Regarding Issues in Screening

General Assistance Recipients & Position Statement

Increasingly, governmental agencies are requiring substance abuse assessment as part of the process of applying for general assistance. When policy makers recognize the value of providing adjunctive services such as substance use counseling and vocational counseling to recipients of general assistance in need of such services, the SASSI can be a helpful tool. Substance use treatment would have a beneficial effect for both the individual and society. However, when public assistance is made contingent on participation in the assessment and treatment process, it increases the risk for violations of ethical principles and applicants’ rights.

If the purpose of your screening program is to identify individuals who may be using controlled substances, rather than identifying a use disorder, then the SASSI does not fit your purposes. The SASSI identifies individuals who have a high probability of being diagnosed with any type of substance use disorder, including alcohol. It is not a measure of the use of controlled substances. There are face-valid screening instruments which are specifically designed to measure drug use and would be a better fit where the client is expected to self-disclose.

Regardless of the design of the program, SASSI screening results do not provide evidence that an individual is using or abusing a controlled substance. Individuals who screen positive on the SASSI may have done so on the basis of subtle scales which are not measures of the use or abuse of any specific substance; or they may have an alcohol use disorder, and may never have misused controlled or illicit substances. A diagnostic interview is necessary to determine for which substances, if any, the client has a substance use disorder.

 

Our Position

Because the SASSI Institute mission is to promote early identification of substance use disorders that ultimately leads to appropriate intervention, treatment, and ongoing recovery, we support screening for substance use disorders among the recipients of general assistance when the program is designed to benefit those recipients and does not infringe or abridge their rights.  Our ultimate goal is to lessen personal suffering and societal costs that accompany substance use disorders.  We strive to accomplish our mission by providing screening instruments for practitioners to use in developing screening programs in a broad range of human service settings, e.g., medical, counseling, criminal justice, vocational. We believe our responsibility is to develop valid and useful measures, to fully disseminate information on the reliability and validity of those measures, and to distribute them to qualified counselors.  Counselors must establish policies regarding the use of assessment instruments in their settings according to appropriate legal, ethical and professional guidelines.

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.

Such comprehensive assessments can be costly, and screening instruments can be of value in reducing overall assessment costs and the number of people who receive unnecessary diagnostic evaluations. However, SASSI screening results do not yield a DSM-5 clinical diagnosis of a Substance Use Disorder and the results should not be used to deny any individual public assistance or employment.

 

Various Modes of Screening

No single measure is able to identify all individuals who have substance use disorders.

 

Body Fluids

Body fluid screens are designed to 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.

It is important to be aware that since the SASSI screens for both alcohol and drug–related substance use disorders, individuals who test positive for having a diagnosable substance use disorder  on the SASSI will not necessarily produce a positive urine screen when screened only for illegal drug use at some later date.  It is very likely that those individuals may have an alcohol use disorder for which the urine screen does not test, but the SASSI does.

 

Questionnaires

Also, no psychological screening instrument is 100% accurate in identifying those with substance use disorders. Invariably, some individuals who do not have a substance use disorder will test positive with high probability results, and some individuals who do have a substance use disorder 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 disorder 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 use disorder is in remission and who do not need help in maintaining sobriety will screen as high probability of having a Substance Use Disorder. The client would be better served by completing a questionnaire that assesses the client’s progress in recovery and level of vulnerability to relapse.

 

Other Considerations

It is vital for a program to pilot its screening procedures in their own individual settings to determine the proportion of their program participants who do not have a substance use disorder who test positive on the measure and are subsequently referred for more thorough assessment.
It is always possible that the samples used to validate a particular screening instrument differ in demographic or other important characteristics from specific subsamples where the instrument is used for screening. These differences may impact screen-positive and screen-negative rates and therefore pilot evaluation of screening results in individual programs is an important first step.

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 program participants who have substance use disorders who test negative on the screening measure 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 those with substance use disorders that are in remission? Does it provide some benefit to individuals who have substance use disorders 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 use disorders.

 

What can the SASSI results tell you?

  • It is important to point out that the SASSI measures are screening instruments used to identify whether individuals have a high or low probability of being clinically diagnosed with a substance use disorder, but these screening results are not themselves sufficient to constitute an official clinical diagnosis of substance use disorder – full clinical evaluations by qualified professionals are necessary to provide these diagnoses.
  • SASSI screening results do not provide evidence that an individual is using or abusing a controlled substance. Individuals who screen positive on the SASSI may have done so on the basis of subtle scales which are not measures of the use or abuse of any specific substance; or they may have an alcohol use disorder, and may never have misused controlled or illicit substances. A diagnostic interview is necessary to determine for which substances, if any, the client has a substance use disorder.
  • Further, individuals in recovery may continue to show a “high probability of substance use disorder” SASSI screening result, even after they have been clean and sober for years. Using the SASSI to eliminate an applicant for a job or social services, ignoring the issue of whether the person is in recovery, violates the purpose of the SASSI and is a violation of the Americans with Disabilities Act.

To download this information, click here:  The SASSI Institute – Screening Issues