
==== Front
Indian J Psychiatry
Indian J Psychiatry
IJPsy
Indian J Psychiatry
Indian Journal of Psychiatry
0019-5545
1998-3794
Wolters Kluwer - Medknow India

IJPsy-66-614
10.4103/indianjpsychiatry.indianjpsychiatry_949_23
Original Article
Assessment of Severity of Substance use for Outcomes Research and Treatment (ASSORT): A substance use severity scale developed and validated across six tertiary care centers in India
Basu Aniruddha
Bhad Roshan 1
Bharadwaj Balaji 2
Bharti Ayushi 3
Choudhury Shinjini 3
Das Prioma
Dinesh M. 2
Guin Aparajita
Joshi Tanmay 4
Krishnan Vijay 4
Kumar Pankaj 3
Mansoori Saba 1
Mishra Ashwani Kumar 1
Nebhinani Naresh 5
Rajpurohit Surendra S. 5
Ranjan Rajeev 3
Sarkar Siddharth 1
Shekhar Saurabh 3
Singh Pranshu 5
Sood Esha 1
Swami Mukesh K. 5
Department of Psychiatry, All India Institute of Medical Sciences, Kalyani, West Bengal, India
1 National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Psychiatry, All India Institute of Medical Sciences, Patna, Bihar, India
4 Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
5 Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
Address for correspondence: Dr. Siddharth Sarkar, Room No 4096, Teaching Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi – 110 029, India. E-mail: sidsarkar22@gmail.com
7 2024
17 7 2024
66 7 614620
13 12 2023
24 6 2024
26 6 2024
Copyright: © 2024 Indian Journal of Psychiatry
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Background and Aims:

Assessment of the severity of substance use disorders (SUDs) in a culture-sensitive manner can help gauge the current condition of the substance user and assess change with time. The present study aimed to develop a scale for the assessment of the severity of SUDs in the Indian clinical context.

Methods:

Based upon the review of literature on previously available instruments and a consultative meeting of experts, a clinician-rated scale was developed that finally comprised 41 items. A briefer 5-item scale with current and lifetime versions was also developed. The scales were applied to patients with SUDs at six different clinical sites.

Results:

The instrument was applied to 720 patients (98.2% males, mean age: 34.6 years). The Cronbach’s alpha of the full scale was 0.852. The inter-rater reliability Pearson correlation coefficient of the full-scale was r = 0.821 (P < 0.001), and the intra-class correlation coefficient single measure was 0.800 (95% confidence interval: 0.724–0.956). A four-factor solution was suggested to be the most tenable. The mean application duration of the full scale was 13.4 minutes, and that of the briefer version was 2 minutes.

Conclusion:

This validated scale could be a potentially useful assessment measure for the severity of SUDs in the Indian context. The utility lies in the simplicity of administration and scoring and the balance between brevity and thorough assessment.

Addiction
assessment
recovery
severity
substance use disorders
treatment
==== Body
pmcINTRODUCTION

Worldwide, substance use disorders (SUDs), particularly alcohol and different drug use disorders are responsible for 4.2% and 1.3% of the disability-adjusted life years (DALYs), respectively.[1] In the Indian context, as per the recent national survey, alcohol use disorder prevalence is 5.2%, cannabis use is 2.8%, and opioid use is 2.1%.[2] In absolute terms, India has about 57 million problem drinkers, 7.2 million problem cannabis users, and 7.7 million problem opioid users. The high prevalence of SUDs across the world has received appropriate health, clinical, political, legal, and research attention. For problem users, different assessment methods are required to ascertain the severity of the disorder. Assessment is generally done by asking questions about the impact of substance use on the lives of patients in various domains. Assessment methods can be substance-specific (for example, the Severity of Alcohol Dependence Questionnaire) or can encompass multiple substances in general which have their advantages and disadvantages (e.g., the Addiction Severity Index, ASI).[34] Among the scales used for the assessment of the severity of SUDs, the ASI is probably the most widely used instrument. The instrument assesses the extent of substance use and the problems associated with it over the time frame of 30 days. The questionnaire takes approximately 30 minutes to complete and is divided into sections of general information, medical status, employment/support status, alcohol/drug use, legal status, family/social status, and psychiatric history. For a total of 200 items in the questionnaire, the scores are generated for each of the domains, and then a summary score can be computed. Given the length of the instrument, attempts have been made to establish a briefer version (the ASI Lite), but that too has more than 150 questions.[5] In addition, the scores of ASI Lite are not in complete agreement with scores on ASI. Hence, there remains a quest for a briefer questionnaire for the assessment of addiction severity in the clinical setting. Furthermore, cultural and health-scenario differences make ASI difficult to implement in the Indian clinical setting. For example, items enquiring into or generating scores based upon the amount spent on drugs/alcohol have no specific conversion in Indian terms. In addition, in the absence of monetary support provided to the unemployed or those with illnesses (compared to the Western world), the employment/support section scores somewhat differently. Hence, the application of ASI in the Indian setting needs careful consideration of these several issues.

The other brief instruments for use in the clinical setting could be the Addiction Severity Assessment Tool (ASAT),[6] the Severity of Dependence Scale,[7] the Maudsley Addiction Profile,[89] the Treatment Outcomes Profile (TOP),[1011] and the Brief Treatment Outcome Measure.[12] Apart from the questionnaire-based instruments discussed, there are several other instruments for assessing the severity.

The currently used scales for the assessment of the severity of SUDs pose challenges of administration in the Indian setting, which is characterized by a higher number of patients and a comparatively smaller number of qualified professionals.[13] Moreover, as per our search, we have not been able to find any specific scale developed in India for the assessment of the severity of SUDs. The present study aimed to indigenously develop a tool for the assessment of SUD severity that is simple in administration (which could be used by a variety of healthcare professionals) and covers a range of a single or a combination of SUDs. Adaptation of scales in different settings needs to factor in cross-cultural issues in ascertainment and application.[141516] India itself is an amalgamation of cultures across regions and settings; thus, scale development should involve an iterative consultative process with multiple stakeholders for better applicability. Hence, the present study was planned to develop a scale to assess SUD-related severity across a variety of settings and clinical scenarios.

METHODS

This study was conducted in four phases as described:

Phase 1. Identification of domains of severity via literature review and consultative iterations

This phase involved the collation of instruments related to addiction severity. A literature review was done using PubMed and Google Scholar to identify the scales dealing with the severity of substance use problems. The items relating to substance use severity for different substances were examined. A consultative process with experts in the field of addiction was used to get direction on the type and length of the instrument, type of grading (self-reported or interviewer-rated), types of responses (dichotomous, open-ended, or Likert rated), scoring methodology, complexity, the applicability of a domain applicable, the mode of use (pen and paper or through app or device), and language first via an online survey and then a physical meeting was done among the collaborators. The concurrences drawn are presented in Table 1. The instrument was named as Assessment of Severity of Substance Use for Outcomes Research and Treatment (ASSORT).

Table 1: Considerations for the scale

Self-rated or clinician-administered: It was decided that the scale should be clinician-administered due to difficulties in the interpretation of questions by lay respondents, low proficiency of reading generally and low literacy in India, and diverse languages across India.	
Grading and scoring: It was decided for the scale to be structured and scored to derive quantitative inferences, facilitate comparisons, and see changes over time. It was decided that questions would not be reverse coded to enable ease of score computation. For uniformity, it was decided to have all questions scored from 1 to 5 in a Likert/ordinal manner though individual questions may have either two responses (coded 1 and 5), three responses (coded 1, 3, and 5), or five responses (coded 1–5). It was decided that there would be no “skip” questions (so the minimum score for a response would be 1).	
Length of the questionnaire: The time of administration was a practical consideration, and it was suggested to develop a longer version of the scale (for a more in-depth assessment) and a shorter version (for a quicker global assessment). It was desired that the duration of application of the questionnaire should be preferably <15 min.	
Lifetime or current problems: It was discussed that the scale should be able to capture both current problems as well lifetime problems associated with substance use.	
Information sources: It was suggested that the professional rating the scale should use as many sources of information available. This is because in the clinical setting, many times family members provide valuable information. However, they should use their clinical judgment for rating if there is discrepancy across informants.	
Substances of use: It was decided that the scale should be able to assess SUDs and should not be limited to one. This was because many SUDs occur together in varying combinations. Common substances for which treatment is sought include alcohol, opioids, and cannabis. For purposes of consideration of abstinence, tobacco was excluded. The instrument did not plan to assess the phenomenology/developmental trajectory of SUDs.	
Domains to be covered: It was decided that the scale should not only cover medical aspects of SUDs but should also be able to capture the impact or experience of problems related to substance use on several domains of life, such as psychological functioning, family relationships, and occupational functioning.	
Language: As English is the language understood commonly by health professionals across the country, it was decided that the questionnaire would be developed in the English language so that it can be applied in a fairly uniform manner.	
Administration to be done by: It was decided that the scale could be administered by any healthcare professional who has some clinical experience in the treatment of individuals with substance use disorders. Some of the questions involved inference of medical causality.	
Mode of use: For the convenience of administration, it was suggested to use the scale in a pen-and-paper format, though it was discussed that in the future, an online version of the scale(s) could be developed and used as a repository.	

Phase 2: Development of a questionnaire based on inputs from various stakeholders

A sample questionnaire was developed and then refined based on the inputs from the experts. This process was done to establish the instrument’s construct validity and face validity. An online survey was conducted to select the items from the model items discussed in the meeting rating the questions on relevance and importance with options to reframe the item by the experts. Based on the experts’ responses, the instrument was developed in two versions: a longer version and a brief version. The initial longer version of the questionnaire had 93 items (13 questions about the physical health domain, 19 about psychological health, 11 about employment and occupation, 8 about patterns of substance use, 8 about legal aspects, 23 about familial and social aspects, and 11 about risk behaviors). The shorter version had five items each for the current (30-day) and lifetime problems with substance use. Subsequently, each of the items was examined for relevance and importance by the experts (each of the items rated on a 5-point Likert scale for relevance and importance) and was closely examined for similarity with each other. The number of questions that finally remained by an expert consensus was 43 in the longer version.

Phase 3. Piloting the questionnaire and modifications based on concerns

The instrument for assessing the severity of substance-related problems (both longer and the brief version) was pilot-tested. Based on the inputs and feedback during pilot testing, modifications were made to the questionnaire, which was further sent to the investigators for comments and refinements. The number of questions was further reduced by 2, and the language of a few questions was modified to bring clarity. Thus, the final longer version consisted of 41 items, and the shorter versions consisted of five items each. The questionnaires are available as a supplementary appendix and are free to use.

Phase 4: Application of the instrument in a multi-center format among patients

The scale was applied across six centers, one in the National Capital Region, one in western India (Jodhpur), one in northern India (Rishikesh), two in eastern India (Patna and Kalyani), and one in southern India (Puducherry). The centers were all government institutions, though they varied in patient load, primary substances of use, types of patients encountered, and duration of being in operation. Treatment-seeking adult patients suffering from dependence or at least one substance among alcohol, opioid, and cannabis as per ICD 10 criteria were included after taking written informed consent. Patients were excluded if they were suffering from psychiatric or medical disorders or features of intoxication or withdrawal that could interfere with the assessment (merely having an additional disorder was not an exclusion). For testing the reliability, the Addiction Severity Index and Addiction Recovery Capital scales were applied for a subset of patients at some of the centers. The application was done by medical officers, nursing officers, and trained/trainee psychiatrists under the supervision of senior consultants experienced in addiction psychiatry. In a subset of the sample, Addiction Recovery Capital was used to assess divergent validity.[1718] The Addiction Severity Index (ASI) was used to compare findings of the scale, though it was clear that ASI provides domain scores primarily. Inter-rater reliability was assessed by the administration of the scale on the same individual by two different raters on the same day through two different assessment interviews. Predictive validity was assessed by looking at the relationship of baseline scale scores with substance use at 1 month and 3 months in a subset of the sample. The data collection lasted from August 2020 to March 2022. The study was approved by the institutional ethics committee of the coordinating institution (IEC 383/07.06.2019, RP 11/2019) and respective institutions where data collection occurred. The study was done according to principles enshrined in the Declaration of Helsinki.

Statistical analysis used descriptive statistics for representing demographic and clinical variables and scale/item scores. Inferential statistics dwelled on the Pearson correlation for understanding the relationship between the scale scores and assessing the relation to ASI domains and Addiction Recovery Capital scores. Inter-rater reliability was determined by correlational analysis and intra-class correlation coefficient with a two-way random model. Factor analysis was done to find out factors for the longer scale. Varimax rotation was used. The Kaiser-Meyer-Olkin Measure and Bartlett’s Test of Sphericity was done to estimate sample adequacy. Scree plot was made, and eigenvalues were determined to find out the number of factors. Analysis was done using SPSS version 21 (IBM Corp, Armonk, NY). Missing data imputation was not done. A P value of less than 0.05 was considered significant.

RESULTS

A total of 720 patients were comprehensively assessed as a part of this project. A total of six centers were used to draw up the participants (Ghaziabad, n = 325, 45.1%; Jodhpur, n = 113, 15.7%; Puducherry, n = 74, 10.3%; Rishikesh, n = 73, 10.1%, Patna, n = 70, 9.7%; and Kalyani, n = 65, 9.0%). The sociodemographic and clinical characteristics of the sample are presented in Table 2. The sample comprised overwhelmingly of males, and the mean age was in the early thirties.

Table 2: Sociodemographic and clinical characteristics of the sample (n=720)

Variable	Mean (SD) or n (Percentage)	
Age in years	34.6 (11.5)	
Male gender	707 (98.2%)	
Currently employed	455 (63.2%)	
Educated above 10th grade	273 (37.9%)	
Urban background	455 (63.2%)	
Nuclear family	445 (61.8%)	
Substance use details		
    Alcohol use	334 (46.4%)	
    Opioid use	318 (44.2)	
    Tobacco use	536 (74.4)	
    Cannabis use	242 (33.6)	
    Sedative hypnotic use	30 (4.2)	
Whether in treatment currently taking medication and/or following up	486 (67.5)	
Injecting drug use ever	120 (16.7)	
Ever admitted for substance use disorder	174 (24.2)	
SD: Standard Deviation

Responses to the individual items of the scale developed for substance-related problems are shown in Supplementary Table 1 for the full scale and in Supplementary Table 2 for shorter versions. The individual item scores are presented in Supplementary Tables 3 and 4. The scale scores of the detailed and short versions are summarized in Table 3, with a mean score of 87.2 ± 20.0 for the full scale and 4.3 ± 2.1 and 5.5 ± 1.9 for the current and lifetime shorter version, respectively. There was a significant positive correlation between the full-scale and short-form (both current and lifetime) versions, as shown in Table 3.

Supplementary Table 1: Responses to individual items of the scale developed for the assessment of substance-related problems

Variable	n	Percentage	
Q1. Duration for which the patient experienced medical problems due to/related to substance use in the last 30 days (e.g., hepatitis,			
    COPD)?			
    1 - Did not experience ever/not applicable	456	63.3	
    2 - Did not experience in the last 30 days, but experienced medical problems in the past	100	13.9	
    3 - Up to 1 week in the last 30 days	62	8.6	
    4-1-2 weeks in the last 30 days	19	2.6	
    5 - >2 weeks in the last 30 days	83	11.5	
Q2. How much has the patient’s usual activities of daily living been affected by medical problems due to/related to substance use in the past 30 days?			
    1 - None/not applicable	471	65.4	
    2 - Mildly	95	13.2	
    3 - Moderately	80	11.1	
    4 - Severely	55	7.6	
    5 - Extremely	19	2.6	
Q3. Rate the patient’s need for medical treatment/admission as per current information available (excluding substance use disorder treatment) (as deemed by the rater, based on history and/or examination) in the last 30 days.			
    1 - No medical issues	442	61.4	
    2 - Medical issues requiring out-patient intervention	173	24.0	
    3 - Medical issues requiring intensive outpatient-based investigations and treatment	60	8.3	
    4 - Medical issues needing in-patient care	40	5.6	
    5 - Medical issues requiring high-dependency or intensive care, or prolonged inpatient stay for>2 weeks	5	0.7	
Q4. Did the patient have episodes of complicated withdrawals related to substance use (e.g., delirium tremens/withdrawal seizures) in their lifetime?			
    1 - No	556	77.2	
    5 - Yes	164	22.8	
Q5. Did the patient have any episode of substance overdose in their lifetime (intoxication related to substance use that has necessitated treatment)?			
    1 - No	563	78.2	
    5 - Yes	157	21.8	
Q6. Did the patient ever develop a chronic medical condition related to substance use (e.g., HIV/malignancy [cancers])?			
    1 - No	661	91.8	
    5 - Yes	59	8.2	
Q7. Has the patient continued to use any substance despite being advised against it during ongoing medical treatment?			
    1 - Did not continue substance use while requiring medical treatment/Never required medical treatment	415	57.6	
    2 - Did not continue substance use while requiring medical treatment in the last 30 days, but did so in the past	74	10.3	
    3 - Continued substance use occasionally even while requiring medical treatment	71	9.9	
    4 - Continued substance use frequently even while requiring medical treatment	59	8.2	
    5 - Continued substance use daily/almost daily even while requiring medical treatment	101	14.0	
Q8. Did the patient become aggressive or did he/she indulge in fights with others due to/related to substance use (including when intoxicated or not intoxicated, instances of domestic violence related to substance use can be included)?			
    1 - Never/not applicable	294	40.8	
    2 - Not in the last 30 days but became aggressive/indulged in fights in the past	188	26.1	
    3 - Yes, but occasionally (<7 days) in the last 30 days	149	20.7	
    4 - Yes, frequently in the last 30 days	68	9.4	
    5 - Yes, daily/almost daily in the last 30 days	21	2.9	
Q9. Did the patient have depressive thoughts such as worthlessness, hopelessness, or helplessness due to/related to substance use?			
    1 - Never/not applicable	204	28.3	
    2 - Not in the last 30 days but felt worthless/hopeless or helpless in the past	138	19.2	
    3 - Yes but occasionally (<7 days) in the last 30 days	178	24.7	
    4 - Yes, frequently in the last 30 days	96	13.3	
    5 - Yes, daily/almost daily in the last 30 days	104	14.4	
Q10. Did the patient experience problems related to memory or concentration due to/related to substance use?			
    1 - Never/not applicable	254	35.3	
    2 - Not in the last 30 days but experienced problems with memory or concentration in the past	109	15.1	
    3 - Yes, but occasionally (<7 days) in the last 30 days	178	24.7	
    4 - Yes, frequently in the last 30 days	106	14.7	
    5 - Yes, daily/almost daily in the last 30 days	73	10.1	
Q11. Did the patient experience problems related to sleep due to/related to substance use (including when on treatment or hospitalized, including withdrawal-related symptoms as well)?	
    1 - Never/not applicable	73	10.1	
    2 - Not in the last 30 days but experienced problems in sleep due to/related to substance use in the past	96	13.3	
    3 - Yes, but occasionally (<7 days) in the last 30 days	88	12.2	
    4 - Yes, frequently in the last 30 days	135	18.8	
    5 - Yes, daily/almost daily in the last 30 days	328	45.6	
Q12. Did the patient have serious problems with mood, anxiety, or mental functioning due to/related to substance use that has required treatment?	
    1 - Did not require treatment for mood, anxiety, or mental functioning ever/not applicable	426	59.2	
    2 - Did not require treatment for mood, anxiety, or mental functioning in the last 30 days, but experienced in the past	153	21.3	
    3 - Required treatment for mood, anxiety, or mental functioning up to 1 week in the last 30 days	43	6.0	
    4 - Required treatment for mood, anxiety, or mental functioning 1 or 2 weeks in the last 30 days	24	3.3	
    5 - Required treatment for mood, anxiety, or mental functioning>2 weeks in the last 30 days	74	10.3	
Q13. Did the patient experience thoughts of harming self or has actually harmed self due to/related to substance use in the last 30 days? (Highest scored option to be selected)			
    1 - Never harmed self and did not have thoughts of harming self in the past	428	59.4	
    2 - Thoughts of harming self in the past	91	12.6	
    3 - Thoughts of harming self in the last 30 days	70	9.7	
    4 - Has harmed self in the past	107	14.9	
    5 - Has harmed self in last 30 days	24	3.3	
Q14. Have the gainful activities (for example, employment) been affected/or influenced by substance use adversely (e.g., missed work, suspension)?			
    1 - Never/not applicable or patient not in gainful employment (for example student/homemaker/retired)	141	19.6	
    2 - Not in the last 30 days, but gainful activities influenced/affected adversely by substance use in the past	183	25.4	
    3 - Up to 1 week in the last 30 days	93	12.9	
    4-1-2 weeks in the last 30 days	58	8.1	
    5 - >2 weeks in the last 30 days	245	34.0	
Q15. Has the patient been economically affected/or has reduced financial contribution towards others due to substance use in the last			
    30 days?	207	28.8	
    1 - None/not applicable	206	28.6	
    3 - Affected to some degree	307	42.6	
    5 - Significantly affected			
Q16. Is the patient’s financial support for substance use gained from others in the last 30 days?			
    1 - None/not applicable	328	45.6	
    3 - Yes, to some degree	141	19.6	
    5 - Yes, significantly	251	34.9	
Q17. Did the patient stop working/or discharging domestic responsibilities/or pursuing education because of substance use in the last 30 days (If a person has more than one role, then kindly provide an impression of the effect of substance use on all roles combined)?			
    1 - None/not applicable	245	34.0	
    3 - Yes, to some degree	199	27.6	
    5 - Yes, significantly	276	38.3	
Q18. Is the patient not able to do what is expected of him/her at the job or fulfill role or responsibilities due to substance use?			
    1 - Never/not applicable	140	19.4	
    2 - Not in the last 30 days but has happened in the past	160	22.2	
    3 - Yes, but occasionally (<7 days) in the last 30 days	123	17.1	
    4 - Yes, frequently in the last 30 days	103	14.3	
    5 - Yes, daily/almost daily in the last 30 days	194	26.9	
Q19. Has the patient been fired from the job/expelled from an educational institute due to substance use?			
    1 - Never/Not applicable	562	78.1	
    3 - Not in the last 30 days, but such a thing has occurred in the past	143	19.9	
    5 - Yes in the last 30 days	15	2.1	
Q20. Did the patient have to borrow money or sell household items to fund substance use?			
    1 - Never/not applicable	296	41.1	
    2 - Not in the last 30 days but in the past	188	26.1	
    3 - Yes, but occasionally (<7 days) in the last 30 days	128	17.8	
    4 - Yes, frequently in the last 30 days	72	10.0	
    5 - Yes, daily/almost daily in the last 30 days	36	5.0	
Q21. Did the patient use multiple substances concurrently (>2 substances excluding tobacco) in the last 30 days?			
    1 - None/not applicable	458	63.6	
    2 - Not in the last 30 days but has happened in the past	134	18.6	
    3 - Yes, but occasionally (<7 days) in the last 30 days	53	7.4	
    4 - Yes, frequently in the last 30 days	34	4.7	
    5 - Yes, daily/almost daily in the last 30 days	41	5.7	
Q22. How many days has the patient used any substance by injectable route in the last 30 days?			
    1 - None/not applicable	603	83.8	
    2 - Not in the last 30 days but has happened in the past	63	8.8	
    3 - Yes, but occasionally (<7 days) in the last 30 days	23	3.2	
    4 - Yes, frequently in the last 30 days	9	1.3	
    5 - Yes, daily/almost daily in the last 30 days	22	3.1	
Q23. Has the patient voluntarily abstained from using all substances (including tobacco) in the last 30 days?			
    1 - Yes, been abstinent completely in the last 30 days	73	10.1	
    2 - Yes, largely abstinent in the last 30 days (occasional substance use)	74	10.3	
    3 - Yes, has been abstinent at least for a few days in the last 30 days	117	16.3	
    4 - Not abstinent in the last 30 days but has been abstinent in the past	94	13.1	
    5 - Never/not applicable	362	50.3	
Q24. How does the patient feel about his/her use of substances currently (information from informants and/or records can also be used to provide an impression)?			
    1 - He/she needs professional help to control substance use.	388	53.9	
    2 - He/she needs some help to control self	101	14.0	
    3 - He/she can control self, but friends and peers can easily influence/information not available	73	10.1	
    4 - He/she can control it and can set limits	100	13.9	
    5 - Not a problem at all	58	8.1	
Q25. Has the patient indulged in any illegal activity (e.g., theft, burglary) linked to substance use without being caught?			
    1 - None/not applicable	560	77.8	
    2 - Not in the last 30 days but has happened in the past	100	13.9	
    3 - Yes, but occasionally (<7 days) in the last 30 days	36	5.0	
    4 - Yes, frequently in the last 30 days	11	1.5	
    5 - Yes, daily/almost daily in the last 30 days	13	1.8	
Q26. Has the patient been driving under the influence of a substance?			
    1 - None/not applicable	194	26.9	
    2 - Not in the last 30 days but has happened in the past	199	27.6	
    3 - Yes, but occasionally (<7 days) in the last 30 days	97	13.5	
    4 - Yes, frequently in the last 30 days	89	12.4	
    5 - Yes, daily/almost daily in the last 30 days	141	19.6	
Q27. Has the patient been involved in drug peddling/drug dealing for substance use?			
    1 - None/not applicable	666	92.5	
    2 - Not in the last 30 days but has happened in the past	36	5.0	
    3 - Yes, but occasionally (<7 days) in the last 30 days	10	1.4	
    4 - Yes, frequently in the last 30 days	6	0.8	
    5 - Yes, daily/almost daily in the last 30 days	2	0.3	
Q28. Did the patient have the following consequences in a partnered relationship due to/related to substance use in their lifetime?			
    1 - None of the above two/not applicable	558	77.5	
    3 - Separation for more than a month	140	19.4	
    5 - Divorce	22	3.1	
Q29. Did the patient have conflicts with spouse/family members due to/related to substance use? Had conflicts:			
    1 - None/not applicable	170	23.6	
    2 - Not in the last 30 days but has happened in the past	181	25.1	
    3 - Yes, but occasionally (<7 days) in the last 30 days	152	21.1	
    4 - Yes, frequently in the last 30 days	132	18.3	
    5 - Yes, daily/almost daily in the last 30 days	85	11.8	
30. Did the patient experience homelessness/eviction from usual residence due to/related to substance use (does not include patient going away from usual residency by self)? Homelessness/eviction experienced:			
    1 - None/not applicable	550	76.4	
    2 - Not in the last 30 days but has happened in the past	102	14.2	
    3 - Yes, but occasionally (<7 days) in the last 30 days	42	5.8	
    4 - Yes, frequently in the last 30 days	17	2.4	
    5 - Yes, daily/almost daily in the last 30 days	9	1.3	
31. Did the patient spend less free time with family members or companions (in case of homeless) than he/she used to, due to/related to substance use? Spent less free time:			
    1 - None/not applicable	129	17.9	
    2 - Not in the last 30 days but has happened in the past	165	22.9	
    3 - Yes, but occasionally (<7 days) in the last 30 days	101	14.0	
    4 - Yes, frequently in the last 30 days	105	14.6	
    5 - Yes, daily/almost daily in the last 30 days	220	30.6	
32. Did the patient’s neighbors and other relatives start to avoid him/her due to/related to his/her substance use?			
    1 - None/not applicable	286	39.7	
    2 - Not in the last 30 days but has happened in the past	134	18.6	
    3 - Yes, but occasionally (<7 days) in the last 30 days	88	12.2	
    4 - Yes, frequently in the last 30 days	71	9.9	
    5 - Yes, daily/almost daily in the last 30 days	141	19.6	
33. Did the patient snatch/steal money or material goods for substance use from family members or companions (in case of homeless) or any other person/agency?			
    1 - None/not applicable	557	77.4	
    2 - Not in the last 30 days but has happened in the past	83	11.5	
    3 - Yes, but occasionally (<7 days) in the last 30 days	49	6.8	
    4 - Yes, frequently in the last 30 days	13	1.8	
    5 - Yes, daily/almost daily in the last 30 days	18	2.5	
34. Does the patient have family or social support as perceived by him/her that could be helpful in the treatment process (as per			
    subjective report)?	432	60.0	
    1 - Always/almost always	125	17.4	
    2 - Most of the time	78	10.8	
    3 - Sometimes	32	4.4	
    4 - Occasionally	53	7.4	
    5 - Never/not applicable			
35. Did the patient neglect the duties towards family members or companions (in case of homeless) due to/related to substance use?			
    1 - None/not applicable	148	20.6	
    2 - Not in the last 30 days but has happened in the past	167	23.2	
    3 - Yes, but occasionally (<7 days) in the last 30 days	127	17.6	
    4 - Yes, frequently in the last 30 days	139	19.3	
    5 - Yes, daily/almost daily in the last 30 days	139	19.3	
36. Did the patient threat the family members or companions (in case of homeless) or create a ruckus at home or with companions due to/related to substance use?			
    1 - None/not applicable	382	53.1	
    2 - Not in the last 30 days but has happened in the past	155	21.5	
    3 - Yes, but occasionally (<7 days) in the last 30 days	95	13.2	
    4 - Yes, frequently in the last 30 days	63	8.8	
    5 - Yes, daily/almost daily in the last 30 days	25	3.5	
37. How frequently did the patient engage in high-risk injecting substance use behavior (sharing, reuse of needle/syringe, or paraphernalia)?			
    1 - Never/not applicable	685	95.1	
    2 - Not in the last 30 days but engaged in high-risk injecting in the past	22	3.1	
    3 - <7 days in the last 30 days	6	0.8	
    4-7-14 days in the last 30 days	2	0.3	
    5 - >14 days in the last 30 days	5	0.7	
38. Was the patient ever abused/or beaten due to/related to substance use (either at home or under the influence or in the company of substance-using peers or others)? Has been abused/beaten:			
    1 - None/not applicable	478	66.4	
    2 - Not in the last 30 days but has happened in the past	145	20.1	
    3 - Yes, but occasionally (<7 days) in the last 30 days	78	10.8	
    4 - Yes, frequently in the last 30 days	12	1.7	
    5 - Yes, daily/almost daily in the last 30 days	7	1.0	
39. Did the patient experience the ending of an important relationship (e.g., spouse, being girlfriend/boyfriend, being disowned) due to/related to substance use?			
    1 - No	583	81.0	
    5 - Yes	137	19.0	
40. Has the patient experienced problems related to sexual functioning due to/related to substance use (e.g., erectile dysfunction, premature ejaculation)?			
    1 - None/not applicable	429	59.6	
    2 - Not in the last 30 days but has happened in the past	100	13.9	
    3 - Yes, but occasionally (<7 days) in the last 30 days	89	12.4	
    4 - Yes, frequently in the last 30 days	66	9.2	
    5 - Yes, daily/almost daily in the last 30 days	36	5.0	
41. Has the patient been arrested/charged/tried/sentenced due to/related to substance use?			
    1 - No/Never	578	80.3	
    3 - Yes, charged/arrested/tried/sentenced in the past	101	14.0	
    5 . Yes, currently charged/arrested/being tried/under sentence	41	5.7	

Supplementary Table 2: Responses to individual items of the short scale developed for the assessment of substance-related problems

Question	n	Percentage	
Short form (current)			
Question 1: Did the patient have medical/psychiatric illness due to/related to substance use that required medical attention			
    0 - None	354	49.2	
    1 - Required outpatient treatment	292	40.6	
    2 - Required inpatient treatment	74	10.3	
Question 2: Did the patient’s substance use impair his/her functioning at work/education/household chores			
    0 - No	160	22.2	
    1 - To some extent but able to carry on these activities,	322	44.7	
    2 - Stopped these activities	238	33.1	
Question 3: Did the patient’s substance use lead to problems with family members			
    0 - No	220	30.6	
    1 - To some extent though family members still living with the patient,	459	63.8	
    2 - To a large extent or a family member has left the patient due to substance use	41	5.7	
Question 4: Number of substances of abuse being taken by the patient (excluding tobacco) in the same month			
    0 - None	110	15.3	
    1 - One or two	522	72.5	
    2 - Three or more	88	12.2	
Question 5: Did the patient experience financial problems due to substance use			
    0 - None or insignificant	245	34.0	
    1 - Significant amount of family income lost in substance use	329	45.7	
    2 - Resorting to debts, selling household items, stealing or snatching money to fund substance use	146	20.3	
Short Form Lifetime			
Question 1: Did the patient have medical/psychiatric illness due to/related to substance use that required medical attention			
    0 - None	362	50.3	
    1 - Required outpatient treatment	241	33.5	
    2 - Required inpatient treatment	117	16.3	
Question 2: Did the patient’s substance use impair his/her functioning at work/education/household chores			
    0 - No	58	8.1	
    1 - To some extent but able to carry on these activities,	324	45.0	
    2 - Stopped these activities	338	46.9	
Question 3: Did the patient’s substance use lead to problems with family members			
    0 - No	105	14.6	
    1 - To some extent though family members still living with the patient,	475	66.0	
    2 - To a large extent or a family member has left the patient due to substance use	140	19.4	
Question 4: Number of substances of abuse being taken by the patient (excluding tobacco) in the same month			
    0 - None	11	1.5	
    1 - One or two	546	75.8	
    2 - Three or more	163	22.6	

Supplementary Table 3: Item scores of the full scale (n=720)

Question	Mean (SD)	
1. Duration for which the patient experienced medical problems due to/related to substance use in the last 30 days (e.g., hepatitis, COPD)?	1.85 (1.36)	
2. How much has the patient’s usual activities of daily living been affected by medical problems due to/related to substance use in the past 30 days?	1.69 (1.10)	
3. Rate the patient’s need for medical treatment/admission as per current information available (excluding substance use disorder treatment) (as deemed by the rater, based on history and/or examination) in the last 30 days.	1.60 (0.91)	
4. Did the patient have episodes of complicated withdrawals related to substance use (e.g., delirium tremens/withdrawal seizures) in their lifetime?	1.91 (1.68)	
5. Did the patient have any episode of substance overdose in their lifetime (intoxication related to substance use that has necessitated treatment)?	1.87 (1.65)	
6. Did the patient ever develop a chronic medical condition related to substance use (e.g., HIV/malignancy [cancers])?	1.33 (1.10)	
7. Has the patient continued to use any substance despite being advised against it during ongoing medical treatment?	2.11 (1.50)	
8. Did the patient become aggressive or did he/she indulge in fights with others due to/related to substance use (including when intoxicated or not intoxicated, instances of domestic violence related to substance use can be included)?	2.08 (1.12)	
9. Did the patient have depressive thoughts such as worthlessness, hopelessness, or helplessness due to/related to substance use?	2.66 (1.39)	
10. Did the patient experience problems related to memory or concentration due to/related to substance use?	2.49 (1.36)	
11. Did the patient experience problems related to sleep due to/related to substance use (including when on treatment or hospitalized, including withdrawal-related symptoms as well)?	3.76 (1.40)	
12. Did the patient have serious problems with mood, anxiety or mental functioning due to/related to substance use that has required treatment?	1.84 (1.30)	
13. Did the patient experience thoughts of harming self or has actually harmed self due to/related to substance use in the last 30 days? (Highest scored option to be selected)	1.90 (1.26)	
14. Have the gainful activities (for example, employment) been affected/or influenced by substance use adversely (e.g., missed work, suspension)?	3.12 (1.57)	
15. Has the patient been economically affected/or has reduced financial contribution towards others due to substance use in the last 30 days?	3.28 (1.67)	
16. Is the patient’s financial support for substance use gained from others in the last 30 days?	2.79 (1.78)	
17. Did the patient stop working/or discharging domestic responsibilities/or pursuing education because of substance use in the last 30 days (If a person has more than one role, then kindly provide an impression of the effect of substance use on all roles combined)?	3.09 (1.70)	
18. Is the patient not able to do what is expected of him/her at the job or fulfill role or responsibilities due to substance use?	3.07 (1.49)	
19. Has the patient been fired from the job/expelled from an educational institute due to substance use?	1.48 (0.95)	
20. Did the patient have to borrow money or sell household items to fund substance use?	2.12 (1.19)	
21. Did the patient use multiple substances concurrently (>2 substances excluding tobacco) in the last 30 days?	1.70 (1.15)	
22. How many days has the patient used any substance by injectable route in the last 30 days?	1.31 (0.85)	
23. Has the patient voluntarily abstained from using all substances (including tobacco) in the last 30 days?	3.83 (1.40)	
24. How does the patient feel about his/her use of substances currently (information from informants and/or records can also be used to provide an impression)?	2.08 (1.38)	
25. Has the patient indulged in any illegal activity (e.g., theft, burglary) linked to substance use without being caught?	1.36 (0.80)	
26. Has the patient been driving under the influence of a substance?	2.70 (1.47)	
27. Has the patient been involved in drug peddling/drug dealing for substance use?	1.11 (0.46)	
28. Did the patient have the following consequences in a partnered relationship due to/related to substance use in their lifetime?	1.51 (1.00)	
29. Did the patient have conflicts with spouse/family members due to/related to substance use? Had conflicts:	2.70 (1.33)	
30. Did the patient experience homelessness/eviction from usual residence due to/related to substance use (does not include patient going away from usual residency by self)? Homelessness/eviction experienced:	1.38 (0.80)	
31. Did the patient spend less free time with family members or companions (in case of homeless) than he/she used to, due to/related to substance use? Spent less free time:	3.17 (1.51)	
32. Did the patient’s neighbors and other relatives start to avoid him/her due to/related to his/her substance use?	2.51 (1.56)	
33. Did the patient snatch/steal money or material goods for substance use from family members or companions (in case of homeless) or any other person/agency?	1.41 (0.89)	
34. Does the patient have family or social support as perceived by him/her that could be helpful in the treatment process (as per subjective report)?	1.82 (1.23)	
35. Did the patient neglect the duties towards family members or companions (in case of homeless) due to/related to substance use?	2.94 (1.42)	
36. Did the patient threat the family members or companions (in case of homeless) or create a ruckus at home or with companions due to/related to substance use?	1.88 (1.15)	
37. How frequently did the patient engage in high-risk injecting substance use behavior (sharing, reuse of needle/syringe or paraphernalia)?	1.08 (0.44)	
38. Was the patient ever abused/or beaten due to/related to substance use (either at home or under the influence or in the company of substance-using peers or others)? Has been abused/beaten:	1.51 (0.83)	
39. Did the patient experience the ending of an important relationship (e.g., spouse, being girlfriend/boyfriend, being disowned) due to/related to substance use?	1.76 (1.57)	
40. Has the patient experienced problems related to sexual functioning due to/related to substance use (e.g., erectile dysfunction, premature ejaculation)?	1.86 (1.23)	
41. Has the patient been arrested/charged/tried/sentenced due to/related to substance use?	1.51 (1.10)	

Supplementary Table 4: Item scores of the short versions of the scale (n=720)

	Mean (SD)	
Short scale (current)		
    Did the patient have medical/psychiatric illness due to/related to substance use that required medical attention?	0.61 (0.67)	
    Did the patient’s substance use impair his/her functioning at work/education/household chores	1.11 (0.74)	
    Did the patient’s substance use lead to problems with family members	0.75 (0.55)	
    Number of substances of abuse being taken by the patient (excluding tobacco) in the same month	0.97 (0.52)	
    Did the patient experience financial problems due to substance use	0.86 (0.72)	
Short scale (lifetime)		
    Did the patient have medical/psychiatric illness due to/related to substance use that required medical attention?	0.66 (0.74)	
    Did the patient’s substance use impair his/her functioning at work/education/household chores	1.39 (0.63)	
    Did the patient’s substance use lead to problems with family members	1.05 (0.58)	
    Number of substances of abuse being taken by the patient (excluding tobacco) in the same month	1.21 (0.44)	
    Did the patient experience financial problems due to substance use	1.22 (0.69)	

Table 3: Scale and brief version scores (n=720)

Scale	Mean (SD)	Correlation	
		Full Scale	Short form current	Short form lifetime	
Full-scale ASSORT	87.2 (20.0)				
Short form current	4.3 (2.1)	0.719**			
Short form lifetime	5.5 (1.9)	0.555**	0.449**		
ASSORT: Assessment of Severity of Substance Use for Outcomes Research and Treatment, **Significant at P<0.01

The Cronbach alpha of the full scale was 0.852. The inter-rater reliability Pearson correlation coefficient of the full-scale was r = 0.821 (P < 0.001), and the intra-class correlation coefficient single measure was 0.800 (95% confidence interval: 0.724–0.956). The Cronbach alpha of the short form of the scale (current and lifetime) was 0.670 and 0.538, respectively. Inter-rater reliability of this short form of the scale (current) was 0.484 (P = 0.014), and the intra-class correlation coefficient single measure was 0.497 (95% confidence interval: 0.141–0.741). The respective inter-rater reliability was 0.572 (P = 0.003), and the intra-class correlation coefficient single measure of the lifetime version was 0.579 (95% confidence interval: 0.252–0.789).

The concurrent application of the scale with the ASI is presented in Supplementary Table 5. It was seen that employment scores, drug scores, legal scores, and psychological scores of ASI had a moderately significant correlation with the full scale. Employment score had a weak correlation with the short form (current) scores, which did not have questions specifically focusing on employment. Otherwise, ASI subscales did not have a significant correlation with the short-form scores, either current or lifetime. The correlation of the full scale with addiction recovery capital was −0.468 (P < 0.001). The correlation coefficients of the short scale, current, and lifetime with the addiction recovery capital, were −0.324 and −0.224, respectively (P = 0.001 and P = 0.018, respectively). Prospective validity was examined by assessing the relationship of baseline scale scores with substance use at 3 months follow-up. The full-scale score or the short-form current and lifetime scores at baseline did not correlate with substance use (apart from tobacco) at 1 month (Spearman ρ = 0.119, 0.194, and 0.091, respectively, with all P > 0.05) and 3 months (ρ = 0.192, 0.040, and 0.026, respectively, with all P > 0.05).

Supplementary Table 5: Correlation of ASI subscale scores and full scale and short form of the scales

Subscale of ASI	Full Scale	Short form (current)	Short form (lifetime)	
Medical	0.166	0.074	0.147	
Employment	0.456**	0.299*	0.210	
Alcohol Score	–0.059	–0.021	–0.225	
Drug Score	0.516**	0.279	0.258	
Legal Score	0.482**	0.259	0.266	
Family Scale	0.216	0.128	0.033	
Psychological Score	0.323*	0.244	–0.053	
ASI: Addiction Severity Index *P<0.05, **P<0.01

The factor analysis of the full scale was done. On an eigenvalue threshold of 1, there would have been 12 factors, but on the Scree plot [Supplementary Figure 1], a 4-factor solution seemed the most tenable which explained 37.7% of the variance. The Kaiser-Meyer-Olkin measure of sampling adequacy score was 0.887. The Bartlett’s test of sphericity approximate Chi-square was 9733.855 (P < 0.001). The component loading of the four-factor solution is presented in Table 4. With a threshold of factor loading of 0.4, a considerable number of items were loaded on the first factor, a few on the second and fourth factor, and none exclusively or primarily on the third factor (two items loaded on the third factor, but they loaded to a greater magnitude on other factors). One, two, and three-factor solutions were also explored. Less than 50% of the items loaded on the first factor in the one-factor solution. Sixteen items did not load on either of the factors in the two-factor solution. In the three-factor solution, 15 items did not load on any of the factors, and the third factor had only one item, making the extension from two to three factors redundant. Alternate analysis was run with normalized item scores (and row normalized item scores). However, these additional analyses did not reveal a better factor structure.

Table 4: Factor loading in the 4-factor solution

	Factor 1	Factor 2	Factor 3	Factor 4	
Item 35	0.793		–0.181		
Item 31	0.752		–0.164		
Item 18	0.743	0.135	–0.222	–0.110	
Item 17	0.726	0.130	–0.323	–0.188	
Item 16	0.716		–0.324	–0.156	
Item 14	0.687	0.132	–0.216	–0.298	
Item 32	0.670	–0.110			
Item 15	0.627		–0.446	–0.118	
Item 20	0.612	–0.116			
Item 29	0.603	0.108			
Item 9	0.544	–0.151			
Item 13	0.519		0.383		
Item 33	0.502		0.375		
Item 36	0.494	0.261	0.273		
Item 8	0.484	0.175	0.350		
Item 11	0.479			–0.227	
Item 38	0.468		0.298		
Item 30	0.460	–0.104	0.271	0.100	
Item 25	0.443	–0.161	0.315		
Item 21	0.439		0.146	0.298	
Item 26	0.389	–0.186	–0.232	0.322	
Item 28	0.339	–0.101	0.255		
Item 39	0.327		0.317		
Item 19	0.324	0.182	0.244	–0.197	
Item 10	0.317	0.147			
Item 2		0.842			
Item 1		0.836			
Item 3		0.807			
Item 7	–0.110	0.653		0.239	
Item 6		0.482			
Item 12		0.253	0.236	–0.164	
Item 34	–0.158	0.208	0.149	0.103	
Item 41		0.135	0.331		
Item 27	0.180		0.306	0.183	
Item 23	0.285	0.198	–0.358	0.518	
Item 24	–0.326		0.402	–0.463	
Item 22	0.363		0.104	0.414	
Item 37	0.178		0.212	0.339	
Item 40	0.211		–0.122	0.261	
Item 4		0.206		–0.254	
Item 5		0.112		0.184	
Factor loading <0.1 is not shown in the table. Those with a factor loading of 0.4 or more are highlighted

The mean time of application of the full scale was 13.4 minutes (standard deviation: 3.8 minutes) while that of short-form was 2.0 minutes (standard deviation: 1.1 minutes).

DISCUSSION

This study led to the development of the Assessment of Severity of Substance Use for Outcomes Research and Treatment (ASSORT), which is a clinician-administered scale for assessing substance use severity. It covers several domains related to the complications of SUDs comprehensively, such as medical, psychiatric, psychosocial, occupational, financial, and legal. Both shorter and longer versions covering both the lifetime and the current situation will widen its scope of applicability. In addition, this scale has been developed with inputs from addiction psychiatry experts across India and has been tested in different centers. This is corroborated by acceptable psychometric properties in the form of Cronbach’s alpha, inter-rater reliability of 0.8, and other acceptable validity measures.

The basis of the scale was a literature review and consultative meeting of addiction psychiatry experts. All three phases of creating a new scale, that is, item development, scale development, and scale evaluation, have been followed.[192021] However, no qualitative methodology was applied for deriving the conceptual framework of substance use severity; thus, the construct validity of the items and the resultant factor structures may be offered scrutiny. A grounded theory approach with inputs from additional stakeholders such as patients and caregivers could have added to the robustness of the study.[22] Such an approach might have shed more light on the dilemma of conceptualizing SUD complications as a unitary concept comprising multiple domains. However, we do acknowledge that drawing concurrence on how severity should be conceptualized across different stakeholders is an arduous challenge, and the present instrument delivers a multifaceted, clinically oriented, and fair assessment of severity.

The fact that the scale was developed and tested in various centers adds to its strength. The settings where this scale was developed and used were diverse, for example, a center in north India running for several decades with a daily footfall of hundreds to a center in eastern India is relatively new with a small patient pool of less severity. The other centers were also variously placed in terms of footfall and other parameters. Moreover, there are sociocultural differences and differences in rates of SUDs across the geographical location of the centers. Thus, we see the representativeness of diverse settings. The sociodemographic and clinical profiles of the patients were akin to the usual profile of treatment-seeking patients at different addiction treatment facilities in India as shown by the Drug Abuse Monitoring System (DAMS).[23]

The convergent validity was checked with ASI, a more firmly established instrument. The overall scale showed significant correlations with only some of the domains (e.g. drug score, legal score, employment, and psychological score). The correlation coefficients were small, even for the correlations that were significant. A possible explanation could be that the present scale looks at some of these aspects more thoroughly than others. Differences in the temporal horizon of the scales may also be a contributing factor. In addition, the patient profile comprised those who were less medically impaired (and hence presented to psychiatry/addiction services). The divergent validity has been established by comparison with the addiction recovery capital, a related but different construct.[17]

An attempt was made to ascertain predictive validity by assessing the relationship between baseline scale scores and outcomes in terms of substance use at 1 and 3 months. However, we did not find an association between the baseline scale scores with substance use/abstinence at 1 and 3 months. The possible reasons could be the influence of treatment. The severity of substance use may one of the many factors that may determine outcomes of patients, and in the present study, it was seemingly a non-significant contributor to substance use outcomes.

On factor analysis, a robust factor structure was not obtained. The four-factor structure was the most tenable. Factor 1 consisted of a wide variety of complications due to substance use, including psychological consequences (items 8 to 13), economic/occupational consequences (items 14 to 20), legal (items 25 to 28), and social and family-related consequences (items 31 to 38). Factor 2 delved with medical complications, factor 3 comprised no items, and factor 4 comprised items that could be construed as frontal lobe-related/cognitive markers of severity (items 21 to 24 and 37). However, we also found items that do not load onto the factors. Sometimes, getting a good factor structure for a scale may be elusive. The factor analysis aims to get an underlying latent structure, and some scales, though useful, may not have a clear factor structure.[24] Notably, ASI also does not seem to have a clear and uniform factor structure, though the utility of the instrument is well recognized.[2526] For a scale to be clinically useful, a robust factor solution is not necessary. Future studies done in a mixture of primary and secondary care settings may yield a different factor structure to the scale with greater differentiation.

The present scale provides an alternate assessment approach to the severity of SUD apart from the traditional instruments developed elsewhere. The scale has proposed applicability in diverse settings and requires minimal previous training for application by physicians. The scores can be used for various purposes, including (but not limited to) assessing the problems currently and in the past ascribable to substance use and tracking the natural longitudinal change in problems. However, as a one-time application, the SUD can assess only cross-sectional SUD problems. The utility of the scale lies in the potential for larger and more diverse applications in the field. The scale might be useful for clinical and research work not only in Indian settings but also in nearby countries and other parts of the world.

There are some limitations of the work. The questions developed and selected for the scale were intended to cover most of the domains of substance use severity, though some important aspects of SUDs were missing, such as spiritual and religious dimensions, which may influence the course and outcome. Furthermore, the perceptions of experts may be different about the severity of SUDs. We developed a consensus working model that encompassed several aspects of the impact of substances on the patient and the family. We included few centers and may not be representative of many other settings (e.g. private settings, camp settings, and primary care settings). Generalizability should also be cognizant of the fact that very few of the respondents were females. Furthermore, we could not have a good marker for prospective validity.

To conclude, the present scale developed assesses the severity of SUDs suitably and efficiently. Developed after the consultative process and cognizant of realities and pragmatics in the Indian clinical setting, the scale offers another tool that can be regularly used for the assessment of severity in the treatment of patients with SUDs. Further studies may look at the performance (both from the psychometric and clinical utility perspective) of this scale. Studies may also look at the severity substance-wise and in select populations such as women, adolescents, the elderly, and gendered minorities. In addition, an online access repository can be considered which carries the assessment details of the scale which makes this data accessible to any health professionals taking care of the patient subsequently.

Financial support and sponsorship

The work was funded by a grant from the Indian Council for Medical Research to Dr Siddharth Sarkar (PI) and others.

Conflicts of interest

There are no conflicts of interest.

Supplementary Figure 1 Scree plot

SUPPLEMENTARY APPENDIX

Assessment of Severity of Substance Use for Outcomes Research and Treatment (ASSORT): - 41 item version

General instructions: This questionnaire is meant for application by doctors and mental health professionals, for patients with substance use disorders. Kindly rate the patient on each of the items. Preferably the interviewer can defer the assessment in case the patient is intoxicated or when the interview is not possible due to serious medical/psychiatric morbidity. However, in such cases, assessment can be attempted if the information is available from other sources such as family members/friends/attendants/medical records or other sources. Rating should be based on the information available in the present situation. In case answers are not clear or forthcoming for any of the items, then the clinicians are suggested to mark according to their best judgment and the collateral information available.

Q1. Duration for which the patient experienced medical problems due to/related to substance use in the last 30 days (e.g., hepatitis, COPD)?	
    1 - Did not experience ever/not applicable	
    2 - Did not experience in the last 30 days, but experienced medical problems in the past	
    3 - Up to 1 week in the last 30 days	
    4-1–2 weeks in the last 30 days	
    5 - >2 weeks in the last 30 days	
Q2. How much has the patient’s usual activities of daily living been affected by medical problems due to/related to substance use in the past 30 days?	
    1 - None/not applicable	
    2 - Mildly	
    3 - Moderately	
    4 - Severely	
    5 - Extremely	
Q3. Rate the patient’s need for medical treatment/admission as per current information available (excluding substance use disorder treatment) (as deemed by the rater, based on history and/or examination) in the last 30 days.	
    1 - No medical issues	
    2 - Medical issues requiring out-patient intervention	
    3 - Medical issues requiring intensive outpatient-based investigations and treatment	
    4 - Medical Issues needing in-patient care	
    5 - Medical issues requiring high-dependency or intensive care, or prolonged inpatient stay for>2 weeks	
Q4. Did the patient have episodes of complicated withdrawals related to substance use (e.g., delirium tremens/withdrawal seizures) in their lifetime?	
    1 - No	
    5 - Yes	
Q5. Did the patient have any episode of substance overdose in their lifetime (intoxication related to substance use that has necessitated treatment)?	
    1 - No	
    5 - Yes	
Q6. Did the patient ever develop a chronic medical condition related to substance use (e.g., HIV/malignancy [cancers])?	
    1 - No	
    5 - Yes	
Q7. Has the patient continued to use any substance despite being advised against it during ongoing medical treatment?	
    1 - Did not continue substance use while requiring medical treatment/Never required medical treatment	
    2 - Did not continue substance use while requiring medical treatment in the last 30 days, but did so in the past	
    3 - Continued substance use occasionally even while requiring medical treatment	
    4 - Continued substance use frequently even while requiring medical treatment	
    5 - Continued substance use daily/almost daily even while requiring medical treatment	
Q8. Did the patient become aggressive or did he/she indulge in fights with others due to/related to substance use (including when intoxicated or not intoxicated, instances of domestic violence related to substance use can be included)?	
    1 - Never/not applicable	
    2 - Not in the last 30 days but became aggressive/indulged in fights in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q9. Did the patient have depressive thoughts such as worthlessness, hopelessness, or helplessness due to/related to substance use?	
    1 - Never/not applicable	
    2 - Not in the last 30 days but felt worthless/hopeless or helpless in the past	
    3 - Yes but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q10. Did the patient experience problems related to memory or concentration due to/related to substance use?	
    1 - Never/not applicable	
    2 - Not in the last 30 days but experienced problems with memory or concentration in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q11. Did the patient experience problems related to sleep due to/related to substance use (including when on treatment or hospitalized, including withdrawal-related symptoms as well)?	
    1 - Never/not applicable	
    2 - Not in the last 30 days but experienced problems in sleep due to/related to substance use in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q12. Did the patient have serious problems with mood, anxiety, or mental functioning due to/related to substance use that has required treatment?	
    1 - Did not require treatment for mood, anxiety, or mental functioning ever/not applicable	
    2 - Did not require treatment for mood, anxiety, or mental functioning in the last 30 days, but experienced in the past	
    3 - Required treatment for mood, anxiety, or mental functioning up to 1 week in the last 30 days	
    4 - Required treatment for mood, anxiety, or mental functioning 1 or 2 weeks in the last 30 days	
    5 - Required treatment for mood, anxiety, or mental functioning for>2 weeks in the last 30 days	
Q13. Did the patient experience thoughts of harming self or has actually harmed self due to/related to substance use in the last 30 days? (Highest scored option to be selected)	
    1 - Never harmed self and did not have thoughts of harming self in the past	
    2 - Thoughts of harming self in the past	
    3 - Thoughts of harming self in the last 30 days	
    4 - Has harmed self in the past	
    5 - Has harmed self in last 30 days	
Q14. Have the gainful activities (for example, employment) been affected/or influenced by substance use adversely (e.g., missed work, suspension)?	
    1 - Never/not applicable or patient not in gainful employment (for example student/homemaker/retired)	
    2 - Not in the last 30 days, but gainful activities influenced/affected adversely by substance use in the past	
    3 - Up to 1 week in the last 30 days	
    4-1–2 weeks in the last 30 days	
    5 - >2 weeks in the last 30 days	
Q15. Has the patient been economically affected/or has reduced financial contribution toward others due to substance use in the last 30 days?	
    1 - None/not applicable	
    3 - Affected to some degree	
    5 - Significantly affected	
Q16. Is the patient’s financial support for substance use gained from others in the last 30 days?	
    1 - None/not applicable	
    3 - Yes, to some degree	
    5 - Yes, significantly	
Q17. Did the patient stop working/or discharging domestic responsibilities/or pursuing education because of substance use in the last 30 days (If a person has more than one role, then kindly provide an impression of the effect of substance use on all roles combined)?	
    1 - None/not applicable	
    3 - Yes, to some degree	
    5 - Yes, significantly	
Q18. Is the patient not able to do what is expected of him/her at the job or fulfill role or responsibilities due to substance use?	
    1 - Never/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q19. Has the patient been fired from the job/expelled from an educational institute due to substance use?	
    1 - Never/Not applicable	
    3 - Not in the last 30 days, but such a thing has occurred in the past	
    5 - Yes in the last 30 days	
Q20. Did the patient have to borrow money or sell household items to fund substance use?	
    1 - Never/not applicable	
    2 - Not in the last 30 days but in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q21. Did the patient use multiple substances concurrently (> 2 substances excluding tobacco) in the last 30 days?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q22. How many days has the patient used any substance by injectable route in the last 30 days?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q23. Has the patient voluntarily abstained from using all substances (including tobacco) in the last 30 days?	
    1 - Yes, been abstinent completely in the last 30 days	
    2 - Yes, largely abstinent in the last 30 days (occasional substance use)	
    3 - Yes, has been abstinent at least for a few days in the last 30 days	
    4 - Not abstinent in the last 30 days but has been abstinent in the past	
    5 - Never/not applicable	
Q24. How does the patient feel about his/her use of substances currently (information from informants and/or records can also be used to provide an impression)?	
    1 - He/she needs professional help to control substance use.	
    2 - He/she needs some help to control self	
    3 - He/she can control self, but friends and peers can easily influence/information not available	
    4 - He/she can control it and can set limits	
    5 - Not a problem at all	
Q25. Has the patient indulged in any illegal activity (e.g., theft, burglary) linked to substance use without being caught?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q26. Has the patient been driving under the influence of a substance?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q27. Has the patient been involved in drug peddling/drug dealing for substance use?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
Q28. Did the patient have the following consequences in a partnered relationship due to/related to substance use in their lifetime?	
    1 - None of the above two/not applicable	
    3 - Separation for more than a month	
    5 - Divorce	
Q29. Did the patient have conflicts with spouse/family members due to/related to substance use? Had conflicts:	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
30. Did the patient experience homelessness/eviction from usual residence due to/related to substance use (does not include patient going away from usual residency by self)? Homelessness/eviction experienced:	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
31. Did the patient spend less free time with family members or companions (in case of homeless) than he/she used to, due to/related to substance use? Spent less free time:	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
32. Did the patient’s neighbors and other relatives start to avoid him/her due to/related to his/her substance use?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
33. Did the patient snatch/steal money or material goods for substance use from family members or companions (in case of homeless) or any other person/agency?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
34. Does the patient have family or social support as perceived by him/her that could be helpful in the treatment process (as per subjective report)?	
    1 - Always/almost always	
    2 - Most of the time	
    3 - Sometimes	
    4 - Occasionally	
    5 - Never/not applicable	
35. Did the patient neglect the duties towards family members or companions (in case of homeless) due to/related to substance use?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
36. Did the patient threaten the family members or companions (in case of homeless) or create a ruckus at home or with companions due to/related to substance use?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
37. How frequently did the patient engage in high-risk injecting substance use behavior (sharing, reuse of needle/syringe or paraphernalia)?	
    1 - Never/not applicable	
    2 - Not in the last 30 days but engaged in high-risk injecting in the past	
    3 - <7 days in the last 30 days	
    4 - 7–14 days in the last 30 days	
    5 - >14 days in the last 30 days	
38. Was the patient ever abused/or beaten due to/related to substance use (either at home or under the influence or in the company of substance-using peers or others)? Has been abused/beaten:	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
39. Did the patient experience the ending of an important relationship (e.g., spouse, being girlfriend/boyfriend, being disowned) due to/related to substance use?	
    1 - No	
    5 - Yes	
40. Has the patient experienced problems related to sexual functioning due to/related to substance use (e.g., erectile dysfunction, premature ejaculation)?	
    1 - None/not applicable	
    2 - Not in the last 30 days but has happened in the past	
    3 - Yes, but occasionally (<7 days) in the last 30 days	
    4 - Yes, frequently in the last 30 days	
    5 - Yes, daily/almost daily in the last 30 days	
41. Has the patient been arrested/charged/tried/sentenced due to/related to substance use?	
    1 - No/Never	
    3 - Yes, charged/arrested/tried/sentenced in the past	
    5 - Yes, currently charged/arrested/being tried/under sentence	

Short form of Assessment of Severity of Substance Use for Outcomes Research and Treatment (ASSORT)

General instructions: This questionnaire is meant for application by doctors and mental health professionals, for patients with substance use disorders. Kindly rate the patient on each of the items. Preferably the interviewer can defer the assessment in case the patient is intoxicated, or when an interview is not possible due to serious medical/psychiatric morbidity. However, in such cases, assessment can be attempted if the information is available from other sources such as family members/friends/attendants/medical records or other sources. Rating should be based on the information available in the present situation. In case answers are not clear or forthcoming for any of the items, then the clinicians are suggested to mark according to their best judgment and the collateral information available.

	Last 30 days	Lifetime	
Question 1: Did the patient have medical/psychiatric illness due to/related to substance use that required medical attention (0) None; (1) Required outpatient treatment, (2) Required inpatient treatment			
Question 2: Did the patient’s substance use impair his/her functioning at work/education/household chores (0) No (1) To some extent but able to carry on these activities, (2) Stopped these activities			
Question 3: Did the patient’s substance use lead to problems with family members (0) No (1) To some extent though family members still living with the patient, (2) To a large extent or a family member has left the patient due to substance use			
Question 4: Number of substances of abuse being taken by the patient (excluding tobacco) in the same month (0) None, (1) One or two (2) Three or more			
Question 5: Did the patient experience financial problems due to substance use (0) None or insignificant, (1) Significant amount of family income lost in substance use, (2) Resorting to debts, selling household items, stealing or snatching money to fund substance use
==== Refs
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