The Exchange

Commentary and Observations from
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Screening for Unhealthy Drug Use

Screening for Unhealthy Drug Use

Despite all the knowledge and technology that we have these days, we still see a vast amount of patients who engage in unhealthy substance use (eg, alcohol, illicit drugs, tobacco) and think that there will be no health consequences. Even if the patient frequently presents to primary care, unhealthy alcohol and other drug use often goes unrecognized. Approaches to alleviate substance use problems include screening, brief interventions, and when appropriate, referral to an addiction treatment program.

The United States Preventive Services Task Force (USPSTF) has recommended that all adults 18 years of age or older—including pregnant and postpartum females—and adolescents aged 12 to 17 years be screened in primary care to identify unhealthy alcohol and drug use. Primary care is ideal for this, as services are often in place to ensure follow-up for diagnosis and treatment. Those with unhealthy use should receive a brief counseling intervention.

Recognizing and helping these at-risk patients does not have to be time-consuming. Screening can be performed simply by asking questions about illegal drugs and prescription medications that are not used for medical purposes. A multitude of screening tools are available for detecting unhealthy alcohol use (eg, AUDIT, AUDIT-C, CAGE) that have been around for years. In recent years, there has been an increase in screening options for drug use and for nonmedical use of prescription drugs.

One screening tool is the National Institute on Drug Abuse Quick Screen; this is a quick screening tool that asks four questions about the use of alcohol, tobacco, nonmedical use of prescription drugs, and illegal drugs in the past year. This test is quite feasible to fit in at busy primary care offices. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a longer test that assesses risks associated with unhealthy drug use, and may reveal information indicating the need for prompt diagnostic assessment. The Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) screening tool may be useful when providers are concerned about prescription misuse. Additionally, the Prenatal Risk Overview (PRO) assessment tool has been found to be reasonably accurate for identifying drug abuse or dependence in pregnant women.

If a patient answers "never" for all substances in the Quick Screen, it is determined to be a negative screen. Patients with a negative screen should be told to continue their abstinence from unhealthy drug and alcohol use. Even after a negative screen, patients should be rescreened annually. Patients who respond "yes" to any of your inquiries should be further questioned; it is important to remain empathetic throughout questioning. If necessary, a brief intervention is the standard treatment for adult patients in primary care who are identified through your screening to have unhealthy alcohol use, including those with a mild substance use disorder. This brief intervention should be aimed at abstinence, or at the very least, reduced substance use. The optimal goal of intervention in primary care for a patient diagnosed with a moderate to severe substance use disorder would be for the patient to willingly begin receiving more extensive treatment for substance use disorder.

  • Patnode CD, et al. Screening for unhealthy drug use: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323:2310-2328.
  • Saitz R. Screening for unhealthy drug use: Neither an unreasonable idea nor an evidence-based practice. JAMA. 2020;323:2263-2265.
  • US Preventive Services Task Force. Screening for unhealthy drug use: US Preventive Services Task Force recommendation statement. JAMA. 2020;323:2301-2309.

Filed under: Public Health, Substance Abuse

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