Study guide
2.2 Standardized Screening Tools: AUDIT, DAST-10, CAGE, CRAFFT & ASSIST
Certified Addictions Registered Nurse CARN
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1 Chapter 1: Introduction & Exam Overview
1.1 CARN Exam Overview, Eligibility & Requirements 1.2 How to Use This Study Guide & Preparation Strategy
2 Chapter 2: Assessment & Screening
2.1 DSM-5-TR Substance Use Disorder Diagnostic Criteria & Severity Classification 2.2 Standardized Screening Tools: AUDIT, DAST-10, CAGE, CRAFFT & ASSIST 2.3 Withdrawal Severity Rating Scales: CIWA-Ar & COWS 2.4 Neonatal & Special Population Assessment: Finnegan, Eat-Sleep-Console & Life Stages 2.5 Assessment of Co-Occurring Psychiatric & Medical Disorders
3 Chapter 3: Planning & Intervention
3.1 ASAM Criteria & Continuum of Placement Care 3.2 Motivational Interviewing (OARS) & Transtheoretical Stages of Change 3.3 Trauma-Informed Care Principles & Addictions Nursing Practice 3.4 Family Dynamics, Codependency, CRAFT Model & Family Support Systems 3.5 Nursing Diagnosis, Outcome Identification & Individualized Addictions Care Planning
4 Chapter 4: Clinical Management & Pharmacotherapy
4.1 Alcohol Withdrawal Syndrome Management & Complication Prevention 4.2 Opioid Withdrawal Management & Symptom-Triggered Protocols 4.3 Medications for Opioid Use Disorder (MOUD: Methadone, Buprenorphine & Extended-Release Naltrexone) 4.4 Pharmacotherapy for Alcohol & Nicotine Use Disorders 4.5 Harm Reduction Strategies: Naloxone, Fentanyl Test Strips & Syringe Services 4.6 Pain Management in Patients with Substance Use Disorders
5 Chapter 5: Substance-Specific Disorders, Prevention & Patient Education
5.1 Stimulant Use Disorders: Cocaine, Amphetamines & Caffeine 5.2 Sedative, Hypnotic, Anxiolytic & Gabapentinoid Misuse 5.3 Cannabis & Hallucinogen Use Disorders 5.4 Tobacco Use Disorder, Vaping & Cessation Interventions 5.5 Prevention, Brief Intervention, Patient Education & Behavioral Addictions
6 Chapter 6: Evaluation, Recovery & Continuing Care
6.1 Relapse Prevention Models: Marlatt's Model, Urge Surfing & High-Risk Situations 6.2 Mutual-Help Groups & Peer Recovery Support: 12-Step, SMART Recovery & Peer Specialists 6.3 Recovery Capital, Social Determinants of Health & Holistic Wellness 6.4 Transitions of Care, Discharge Planning & Long-Term Recovery Management
7 Chapter 7: Professional Role, Ethics & Legal Issues
7.1 ANA/IntNSA Scope & Standards of Addictions Nursing Practice 7.2 Confidentiality Laws: 42 CFR Part 2 vs. HIPAA & 2024 Alignment Updates 7.3 Legal & Ethical Issues, Stigma Reduction & Person-First Language
2.2 Standardized Screening Tools: AUDIT, DAST-10, CAGE, CRAFFT & ASSIST
Key Takeaways Explain This Topic AI
AUDIT (Alcohol Use Disorders Identification Test) is a 10-item WHO tool; total scores range 0–40 (0–7 low risk, 8–15 moderate risk requiring brief intervention, 16–19 high risk requiring counseling/monitoring, 20–40 severe risk requiring specialist referral).
CAGE is a concise 4-item screening mnemonic (Cut down, Annoyed, Guilty, Eye-opener); a score of ≥2 is clinically significant and indicates high risk for alcohol dependency.
DAST-10 measures non-alcohol drug misuse over the past 12 months; score 0 = no problem, 1–2 = low risk, 3–5 = moderate risk, 6–8 = substantial risk, 9–10 = severe risk.
CRAFFT is specifically validated for adolescents (<21 years); Part B evaluates a 6-item mnemonic (Car, Relax, Alone, Forget, Friends, Trouble), with a score ≥2 indicating high risk for substance-related harm.
WHO ASSIST calculates a Specific Substance Involvement (SSI) score ranging from 0–3 (low risk), 4–26 (moderate risk requiring brief intervention), to ≥27 (high risk requiring intensive specialist treatment).
Last updated: August 2026
- Standardized Screening Tools: AUDIT, DAST-10, CAGE, CRAFFT & ASSIST
- Universal Screening in Addictions Nursing
Universal screening for substance misuse is a foundational component of evidence-based nursing assessment. Early identification of unhealthy alcohol and drug use prevents disease progression, reduces trauma and injury rates, and improves overall medical outcomes. Screening differs fundamentally from diagnostic assessment: while diagnostic evaluation (such as DSM-5-TR scoring) establishes the formal presence of a disorder, screening rapidly categorizes individuals along a risk continuum to guide immediate clinical intervention.
The American Society of Addiction Medicine (ASAM) and the Substance Abuse and Mental Health Services Administration (SAMHSA) advocate for the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model across all healthcare settings, including primary care, emergency departments, trauma centers, and inpatient units.
Alcohol Use Disorders Identification Test (AUDIT & AUDIT-C)
Developed by the World Health Organization (WHO), the Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening instrument designed to detect hazardous and harmful alcohol consumption as well as alcohol dependence.
AUDIT Structure & Item Domains
Items 1–3 (Consumption Domain): Assess frequency of drinking, typical quantity consumed, and frequency of heavy episodic drinking (binge drinking: ≥5 drinks for men, ≥4 drinks for women).
Items 4–6 (Dependence Symptoms): Assess impaired control over drinking, increased salience of drinking, and morning drinking.
Items 7–10 (Alcohol-Related Consequences): Assess guilt, blackout/amnesia, alcohol-related injuries, and concerns expressed by relatives or health professionals.
Each item is scored from 0 to 4, yielding a total score between 0 and 40 .
AUDIT Risk Stratification & Clinical Intervention Matrix
Zone Total AUDIT Score Risk Level Recommended Clinical Intervention (SBIRT)
Zone I 0 – 7 Low Risk / Abstinent Alcohol education and primary prevention messages.
Zone II 8 – 15 Moderate Risk (Hazardous) Brief Intervention (BI): Motivational advice to reduce drinking limits.
Zone III 16 – 19 High Risk (Harmful) Brief Counseling & Monitoring: Repeated BI plus specialized outpatient monitoring.
Zone IV 20 – 40 Severe Risk (Possible Dependence) Referral to Treatment (RT): Diagnostic evaluation and specialist addiction treatment.
The AUDIT-C Abbreviated Screen
The AUDIT-C consists exclusively of the first 3 consumption questions. Total scores range from 0 to 12. Cut-off scores indicating a positive screen are ≥4 for adult men and ≥3 for adult women and older adults . A positive AUDIT-C prompts administration of the full 10-item AUDIT.
Drug Abuse Screening Test (DAST-10)
The Drug Abuse Screening Test (DAST-10) is a 10-item self-report scale designed to screen for non-alcohol drug misuse over the preceding 12 months. Items are answered with a binary "Yes" (1 point) or "No" (0 points).
DAST-10 Clinical Scoring Breakdown
Score 0: No problem reported. Action: Encouragement and standard health monitoring.
Score 1 – 2: Low level of risk. Action: Brief intervention focused on harm reduction.
Score 3 – 5: Moderate (Intermediate) level of risk. Action: Intensive brief intervention and further diagnostic evaluation.
Score 6 – 8: Substantial level of risk. Action: Formal assessment, referral to specialized addiction treatment program.
Score 9 – 10: Severe level of risk. Action: Immediate referral to specialized addiction treatment specialist or inpatient medical detox.
CAGE Questionnaire: Utility & Limitations
The CAGE questionnaire is one of the most widely recognized brief alcohol screening tools in clinical medicine. It consists of four direct questions represented by the CAGE mnemonic:
C – Cut down: Have you ever felt you needed to C ut down on your drinking?
A – Annoyed: Have people A nnoyed you by criticizing your drinking?
G – Guilty: Have you ever felt bad or G uilty about your drinking?
E – Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover ( E ye-opener)?
Scoring & Interpretation
Each "Yes" response receives 1 point (total score 0 to 4).
Score of 0 – 1: Low suspicion for alcohol dependence.
Score of ≥2: Clinically significant positive screen. Indicates high risk of alcohol dependency and requires thorough diagnostic workup.
CARN Clinical Note: CAGE is highly sensitive for lifetime alcohol dependence but lacks sensitivity for detecting early hazardous drinking patterns. Furthermore, CAGE does not establish a timeframe (e.g., past 12 months), meaning historical drinking may yield a false-positive screen in long-term recovery. For current drinking risk, AUDIT is superior.
CRAFFT Screening for Adolescent Populations
The CRAFFT screening tool is explicitly validated for children, adolescents, and young adults aged 12 to 21 years. CRAFFT integrates screening for both alcohol and illicit/prescription drugs.
CRAFFT Structure
Part A: Asks about frequency of use in the past 12 months (alcohol, cannabis, other substances).
Part B (The CRAFFT Mnemonic): If the adolescent reports any use in Part A, the nurse administers the 6 Part B items:
Letter Item Question
C Have you ever ridden in a C ar driven by someone (including yourself) who was high or had been using alcohol or drugs?
R Do you ever use alcohol or drugs to R elax, feel better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are by yourself, A lone?
F Do you ever F orget things you did while using alcohol or drugs?
F Do your F amily or F riends ever tell you that you should cut down on your drinking or drug use?
T Have you ever gotten into T rouble while you were using alcohol or drugs?
Scoring Thresholds
A score of ≥2 on Part B indicates a positive screen, signaling high risk for a substance use disorder or hazardous substance involvement, requiring brief motivational counseling and developmental specialist referral.
WHO ASSIST: Multi-Substance Screening
The Alcohol, Smoking and Substance Involvement Screening Test (WHO ASSIST) is an 8-item interviewer-administered tool designed to evaluate ten substance categories: tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, opioids, and other drugs.
ASSIST yields a Specific Substance Involvement (SSI) score for each substance:
0 – 3 (Alcohol 0 – 10): Low risk. Standard health advice.
4 – 26 (Alcohol 11 – 26): Moderate risk. Brief intervention and educational materials.
27+ (Alcohol 27+): High risk. Referral to specialist treatment.