NIDA Modified ASSIST

1. In your LIFETIME, which of the following substances have you ever used? *Note for Physicians: For prescription medications, please report nonmedical use only.

Rows	Yes	No
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium,Rohypnol, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other – specify:

2. In the past three months, how often have you used the substances you mentioned (first drug, second drug, etc)?

Rows	Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other – Specify:

3. In the past 3 months, how often have you had a strong desire or urge to use (first drug, second drug, etc)?

Rows	Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other – Specify:

4. During the past 3 months, how often has your use of (first drug, second drug, etc) led to health, social, legal or financial problems?

Rows	Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other – Specify:

5. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of (first drug, second drug, etc)?

Rows	Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other – Specify:

6. Has a friend or relative or anyone else ever expressed concern about your use of (first drug, second drug, etc)?

Rows	No, Never	Yes, but not in the past 3 months	Yes, in the past 3 months
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other – Specify:

7. Have you ever tried and failed to control, cut down or stop using (first drug, second drug, etc)?

Rows	No, Never	Yes, but not in the past 3 months	Yes, in the past 3 months
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other – Specify:

8. Have you ever used any drug by injection (NONMEDICAL USE ONLY)?

Rows	No, Never	Yes, but not in the past 3 months	Yes, in the past 3 months
1

Substance Involvement Score

a. Cannabis (marijuana, pot, grass, hash, etc.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Xanax, Ativan, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street Opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

j. Other