By far, the most commonly noted specialized tools used to identify substance abuse problems are the CAGE and the Substance Abuse Subtle Screening Inventory (SASSI). These tools were most commonly mentioned by both TANF agencies screening for substance abuse problems as well as substance abuse experts. The CAGE's popularity is likely due to its ease of administration. A short tool, it consists of only four questions that require no training to administer. Not surprisingly, the CAGE was found to be used widely both as a stand-alone tool and incorporated into tools designed to identify multiple barriers to employment. Originally developed for individuals already known to be drinking, the CAGE is designed to assess whether alcohol use is a problem. The CAGE is currently being used more broadly in welfare offices and by others to identify whether or not an individual is using alcohol or drugs. Some in the substance abuse field expressed concern about TANF agencies using the CAGE this way, given this was not its intended purpose.
The SASSI is also popular for its ease of administration. Although the SASSI (78 questions) is a longer tool than the CAGE (four questions), it can be administered quickly and easily. Unlike the CAGE, administration of the SASSI requires training and comes at a cost to agencies.
Despite the popularity of the CAGE and SASSI, there are a number of other tools that can be used to identify substance use. The U.S. Department of Health and Human Services, Center for Substance Abuse Treatment created the Simple Screening Instrument for Alcohol and Other Drug Abuse.61 The Simple Screening Instrument is 16 'yes' or 'no' questions regarding consumption, problem recognition, experience with adverse consequences, and awareness of a past or present problem with alcohol and other drugs, among other things. According to the implementation guidelines, it can be used by a diverse group of outreach workers, paraprofessionals, and professionals in the fields of both alcohol and drug abuse and infectious diseases.
According to the recent report by the National Center on Addiction and Substance Abuse (CASA), the State of North Carolina is actively attempting to identify substance abusers from among the TANF population. The North Carolina Department of Social Services has entered into a process of using both TANF staff and Qualified Substance Abuse Professionals62 to assist with the identification of substance abuse problems. All TANF applicants and recipients are supposed to be screened for alcohol and substance abuse problems. County offices determine which staff will conduct the initial screening (either Department of Social Services staff or Qualified Substance Abuse Professionals) and the procedures that work best for their office. The initial screen can be conducted using one of two other types of substance abuse tools: the Alcohol Use Disorder Identification Test (AUDIT) or the Drug Use Questionnaire (DAST-10). If either of these tools indicates a problem, the client is referred to the QSAP for in-depth assessment using the Substance Use Disorder Diagnostic Schedule (SUDDS-IV).63
61 More recently, the Center for Substance Abuse Treatment has undertaken an effort to prepare a Technical Assistance Publication addressing screening and assessing for substance abuse problems among TANF clients (forthcoming).
62 Qualified Substance Abuse Professionals are employed by local mental health authorities but in some cases are located in DSS offices.
63 National Center on Addiction and Substance Abuse August 1999, pp. 39-40.