Beyond the AUDIT: using the DAST-10 and WHO-ASSIST in primary care
The AUDIT's success in Australian primary care has created an implementation gap for drug use screening that deserves more clinical attention. While alcohol screening has become at least intermittently routine, equivalent validated tools for identifying harmful drug use remain dramatically underused in primary care despite robust evidence bases and comparable brevity.
This matters clinically. As cocaine, methamphetamine, prescription opioid, and benzodiazepine presentations become more common in general practice , a trend documented in the National Wastewater Drug Monitoring Programme data and the Australian Institute of Health and Welfare , the absence of systematic drug screening represents a real gap in preventive care.
Two instruments deserve specific attention: the DAST-10 and the WHO-ASSIST.
The DAST-10
The Drug Abuse Screening Test, developed by Harvey Skinner and validated across multiple decades and populations, is the most direct analogue to the AUDIT for illicit and non-medical drug use. The current standard version , the DAST-10 , consists of 10 yes/no questions covering the past 12 months, can be completed in under three minutes, and has strong sensitivity and specificity for identifying drug use disorders across a range of substances.
The questions cover:
- Use of drugs other than alcohol/tobacco
- Misuse of prescription drugs
- Multiple drug use
- Self-perception of problematic use
- Loss of control over drug use
- Drug use in relation to social, family, or legal consequences
- Drug use as a coping mechanism for personal problems
Scoring interpretation:
| Score | Classification | Clinical implication |
|---|---|---|
| 0 | No problems reported | No clinical action indicated |
| 1–2 | Low level | Education and monitoring |
| 3–5 | Moderate | Brief intervention; counselling recommended |
| 6–8 | Substantial | Assessment for treatment; possible specialist referral |
| 9–10 | Severe | Assessment for treatment; likely specialist referral |
The DAST-10 is freely available and requires no licensing. It can be self-administered in the waiting room or integrated into intake paperwork, reducing the clinical time required to zero.
One limitation: the DAST-10 does not differentiate between substance types, producing a single severity score regardless of the specific drug(s) involved. For clinical purposes, this typically means the DAST-10 is an appropriate initial screen that, on a positive result, leads to a more substance-specific clinical conversation.
The WHO-ASSIST
The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), developed by the World Health Organisation and validated across multiple countries including Australia, addresses the DAST-10's limitation by generating separate risk scores for each of eight substance categories: tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives/sleeping pills, hallucinogens, and opioids.
The ASSIST consists of 8 items per substance, but in practice is completed more quickly than this sounds , substances the patient has not used at all are skipped, meaning the tool is brief for patients with a limited substance use profile and more extended for those with complex polydrug use.
The risk scores and clinical thresholds for each substance:
| Score | Risk level | Recommended response |
|---|---|---|
| 0–3 | Low | No action (optional education) |
| 4–26 | Moderate | Brief intervention (ASSIST-linked BI available) |
| 27+ | High | Brief intervention plus referral to specialist services |
The thresholds differ by substance , the specific cut-offs are documented in the WHO ASSIST implementation guide, which also includes a validated brief intervention framework directly linked to the tool. The linked brief intervention (ASSIST-BI) is a structured 3–5 minute motivational conversation using the assessment results as the clinical substrate , directly comparable to what the AUDIT enables for alcohol.
Clinical advantages of the ASSIST over the DAST-10:
- Substance-specific risk scores enable targeted brief intervention
- Covers prescription drug misuse (sedatives, opioids) specifically
- The WHO-ASSIST training package is available free online and is specifically designed for non-specialist settings
- The linked brief intervention protocol is validated and integrable into a standard 10–15 minute consultation
Practical disadvantage: the ASSIST takes longer to administer than the DAST-10, particularly in patients with complex polydrug profiles. For practices wanting to implement systematic drug screening with minimal workflow disruption, offering the DAST-10 as an initial screen , with the ASSIST reserved for positive screens or more comprehensive assessments , is a reasonable approach.
Implementation in practice
The implementation lessons from AUDIT rollout in Australian primary care are directly applicable. The evidence from alcohol screening implementation research is consistent on several points:
Waiting room administration substantially reduces the clinical time required and reduces the social discomfort of face-to-face drug use enquiry. Patients are more willing to disclose accurately on paper or tablet than in direct questioning , the same principle underlying the case for anonymity in self-monitoring tools, discussed in why anonymity improves self-reporting.
Integration into standard intake processes , health assessment forms, Health Check paperwork, mental health care plan assessments , normalises screening as a routine clinical activity rather than a targeted enquiry that communicates suspicion.
The clinical conversation following a positive screen benefits from the same principles that underpin effective brief alcohol intervention. A moderate ASSIST score on methamphetamine is not an opportunity for a lecture about drug use; it is an opportunity for a motivational conversation exploring the patient's own ambivalence and concerns. For practical guidance on this, see methamphetamine in your caseload for stimulant-specific considerations and cocaine in your caseload for cocaine presentations.
A note on pharmaceutical drug misuse
The ASSIST specifically includes sedatives/hypnotics and opioids as categories, making it the more appropriate instrument for identifying non-medical use of prescribed medications , a significant and growing clinical concern in Australian primary care given the prevalence of benzodiazepine dependence and prescription opioid misuse documented in the AIHW data.
The DAST-10, though broad, does include a question on prescription drug misuse. Either instrument will identify this population for clinical follow-up.
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