Substance Use Frequency and Risk Level

Screening combined with clinical judgement and additional assessments as needed helps physicians assess for potential substance use problems. The problem or severity of substance use may be measured in a variety of ways, but for purposes of consistency for this EQIPP project, it is defined by risk level, which is measured by:

1. Frequency of use; and/or

2. CRAFFT score

Frequency identifies how often the substance has been used in the prior year; a recent research study¹ correlated frequency of use with the risk level for having a substance use disorder (SUD). Thus, if using the S2BI screening tool or other tool that considers frequency, risk level is expressed as follows:

FREQUENCY (in prior year)	RISK LEVEL
0 or never	None, no current risk for SUD
Once or twice	None, no current risk for SUD
Monthly or more	Mild to moderate risk for SUD
Weekly or more frequent	Severe risk for SUD

The CRAFFT tool, used first as a screener and then as an assessment tool to explore “yes” responses, helps reveal the extent of the patient’s substance use-related problems. A score of 2 or greater indicates a potential problem and need for additional assessment. Risk level may broadly be expressed as follows (not intended as a complete CRAFFT scoring/interpretation guide):

CRAFFT SCORE	RISK LEVEL
0	None, no current risk for SUD
CRAFFT score <2	Mild risk for SUD
CRAFFT score 3–4	Moderate risk for SUD
CRAFFT score ≥5	Severe risk for SUD

Note: Current recommendations focus on measuring frequency of substance use. Therefore, when using the CRAFFT tool, it is recommended that the clinical interview also identifies the frequency of use. This combined information of frequency and risk level can contribute to decisions regarding next steps for patient care, namely continued conversation concerning safety/anticipatory guidance issues and behavior change managed in the medical home or referral for more specialized substance use evaluation, intervention, and/or treatment.

For Your Reference

Recall that screening helps identify individuals at risk or with a substance use problem; it does not diagnose an SUD. However, evidence-based screening tools are validated against diagnostic criteria to determine if the screens are measuring the same constructs as the diagnosis. For this reason, when using the CRAFFT as a screening and/or assessment tool, it may be helpful to better understand the diagnostic criteria for SUDs. Note that a DSM-5 diagnosis categorizes SUDs according to how many criteria were identified:

Mild SUD = 2 or 3 DSM-5 SUD criteria met
Moderate SUD = 4 or 5 DSM-5 SUD criteria met
Severe SUD = 6 or more DSM-5 SUD criteria met

The criteria for substance use disorders summarized below are described fully on pages 483–484 of the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition.² These criteria can be considered to fit within overall groupings of impaired control, social impairment, risky use, and pharmacological criteria.

Criteria for Substance Use Disorders
Impaired Control	Using the substance in larger amounts or for a longer period than originally intended
	Wanting to cut down or stop using the substance but not being able to
	Spending a lot of time obtaining, using, or recovering from use of the substance
	Having cravings and urges to use the substance
Social Impairment	Failure to fulfill major role obligations at work, home, or school because of substance use
	Continuing to use, even when it causes problems in relationships
	Giving up or reducing important social, occupational, or recreational activities because of substance use
Risky Use	Using substances again and again, even when it puts the individual in danger
	Continuing to use, even when a physical or psychological problem could have been caused or made worse by the substance
Pharmacological Criteria	Needing more of the substance to get the desired effect (tolerance)
	Developing withdrawal symptoms, which can be relieved by taking more of the substance

¹Levy S, Weiss R, Sherritt L, et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatr. 2014;168(9):822–828

² Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Association; 2013

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