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Research Summary

Substance Use Screening Does Not Need to Be Subtle

The Substance Abuse Subtle Screening Inventory (SASSI) was designed to assess substance use disorders in patients who may not answer questions truthfully for various reasons (e.g., denial, wanting to please their clinician). To summarize research on the SASSI, investigators conducted a systematic review of 36 peer-reviewed articles on the instrument’s performance in a total of 22,110 patients.

  • There was high internal consistency* for the direct but not the indirect (or subtle) components of the SASSI.

  • The sensitivity of the SASSI was 70% (weighted mean); the specificity was 62%.**


Screening for substance use disorders is an initial step in diagnosis and treatment. Clinicians may be concerned that direct questions make it easier for patients to provide socially desirable, rather than honest, answers. This research, however, indicates that subtle screening methods do not necessarily have good operating characteristics and clinical utility. Further, other studies show that more-direct questions work quite well.

David A. Fiellin, MD
*How consistently questions measure the variable of interest (in this case, substance use disorders)
**Sensitivity is the proportion of patients with a disorder that test positive; specificity is the proportion of patients without a disorder who test negative.


Feldstein SW, Miller WR. Does subtle screening for substance abuse work? A review of the Substance Abuse Subtle Screening Inventory (SASSI). Addiction. 2007;102(1):41–50.