New Primary Care Tool Detects Problem Substance Use

Diana Swift

September 07, 2016

A fast, flexible screening instrument, developed for easy integration into primary care work flows, is effective for uncovering patients' problem substance use, according to a study published online September 6 in the Annals of Internal Medicine.

The Tobacco, Alcohol, Prescription Medication, and Other Substance use (TAPS) tool detected clinically relevant problem use in a diverse population of 2000 adult patients from five primary care centers in New York City; Baltimore, Maryland; and Richmond, Virginia. Interviewer- and self-administered versions of the tool were validated by comparison with a gold-standard reference instrument, the modified Composite International Diagnostic Interview (CIDI), which measures both problem use and actual substance use disorder (SUD).

Although completion time varies with the number of substances screened for, "TAPS takes in the realm of 2 to 5 minutes. The CIDI is more in the realm of 15 to 30 minutes," lead author Jennifer McNeely, MD, an assistant professor at New York University School of Medicine in New York City and a general internist specializing in addiction medicine, told Medscape Medical News. "This is intended as a brief initial assessment tool for use in primary care in a pretty universal screening paradigm. You could use it to screen every patient who comes in the door for unhealthy substance use.

"And in comparison with previous brief instruments for identifying misuse, TAPS takes the next step and identifies specific substances and the patient's level of risk," she said.

Recently presented data indicate that physicians do not routinely screen even for the widespread problem of alcohol abuse.

In the identification of problem use, TAPS had a sensitivity of 0.93 (95% confidence interval [CI], 0.90 - 0.95) and a specificity of 0.87 (95% CI, 0.85 - 0.89) for tobacco. For alcohol abuse, it had a sensitivity of 0.74 (95% CI, 0.70 - 0.78) and a specificity of 0.79 (95% CI, 0.76 - 0.81). In the case of illegal and prescription drug misuse, sensitivity ranged from 0.82 (95% CI, 0.76 - 0.87) for marijuana to 0.63 (95% CI, 0.47 - 0.78) for sedatives. Specificity was higher, at 0.93 or greater.

However, for identifying any actual disorder, TAPS' sensitivity was lower, so the authors concede that "further refinement is needed before it can be recommended broadly for SUD screening." For instance, the low prevalence of use for some drug classes yielded imprecise estimates.

The mean age of study patients was 46.0 years (standard deviation, 14.7 years), 56.2% were women, and 55.6% were African-American. In terms of past-year substance use, as measured by the CIDI, 62.0% were positive for alcohol, 44.1% for tobacco, 25.6% for illicit drugs, and 7.4% for prescription drugs. Specifically, 20.8% had used marijuana, 7.3% cocaine, and 7.3% opioids (prescription or heroin).

Encouragingly for primary care use, 99% of participants felt comfortable answering the TAPS questions, and 95% said they would be comfortable sharing the results with their doctors.

For participants who underwent oral fluid testing, point prevalence was 11.3% for illicit substance use and 5.0% for nonmedical use of prescription medications.

Because it asks few questions and can be self-completed or interviewer-administered, TAPS has the potential to ease current barriers to screening in busy clinical environments.

"It's ready for prime time as a screening tool for identifying use that is causing problems and patients who are at risk for more severe SUDs," Dr McNeely said. "Where it doesn't perform perfectly is in distinguishing between these and people who already have a severe SUD. It's not very sensitive for identifying SUDs for drugs other than marijuana."

Further analysis of the data may clarify why TAPS missed people with SUDs, possibly because they had curtailed their misuse in the past 3 months and therefore did not have a positive score, Dr McNeely said.

Primary funding for this study was provided by the National Institute on Drug Abuse (NIDA). Several study authors reported grants from NIDA or employment with NIDA partners, and one author disclosed a consulting reimbursement from the private sector outside the submitted work.

Ann Intern Med. Published online September 6, 2016. Abstract

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