New National Guidance on Screening for Illicit Drug Use

Pauline Anderson

June 09, 2020

A national expert task force has issued new guidance on screening for unhealthy drug use in adult patients.

Karina W. Davidson, PhD

Based on the latest evidence, the US Preventive Services Task Force (USPSTF) recommends that in the primary care setting all patients 18 years of age and older be screened for illicit drug use and misuse of prescription medications.

"Unhealthy drug use can have a devastating impact on people and families, but the good news is that clinicians can do something to help," Karina W. Davidson, PhD, USPSTF vice chair, told Medscape Medical News.

Davidson is senior vice president of research, and dean of academic affairs, at the Feinstein Institutes for Medical Research at Northwell Health, Long Island, New York.

The final recommendation was published online June 9 in JAMA.

Referral to Treatment Critical

An estimated 12% of US adults and 8% of adolescents ages 12 to 17 years report unhealthy use of prescription or illegal drugs, one of the most prevalent preventable causes of death, injury, and disability in the United States, said Davidson.

A 2008 report by the USPSTF concluded there was insufficient evidence at that time to recommend universal drug screening for adults or adolescents.

To update this recommendation the task force commissioned reviews of the evidence on screening. They found no randomized controlled trials examining outcomes of screening versus not screening in asymptomatic adult patients with no diagnosis of drug abuse.

Screening adults, including pregnant women, involves asking one or more questions about drug use or drug-related risks in a face-to-face, print, or audio-visual format. It does not involve urine, saliva, or blood testing for the presence of drugs. The new recommendation does not pertain to patients already diagnosed with a substance use disorder.

Other reviews examined the accuracy of available screening tests and evidence that interventions reduce related negative outcomes.

"We found many more short, reasonable, and valid screener tests showed evidence that interventions work to either improve abstinence or reduce relapse," said Davidson.

The investigators concluded that screening for unhealthy drug use in adults has "moderate net benefit" but only when diagnostic and treatment services are available.

"We did not find evidence that screening alone, without effective treatment, is beneficial," said Davidson.

"Clinicians should ensure they have the appropriate referrals for diagnostic work-up and effective treatment, and that they have those ready at hand if someone does screen positive."

Davidson acknowledged that screening in adults may have potential "complications" that could lead to unintended harms including privacy issues, discouraging patients who don't want to be screened from seeking healthcare, and possible medical and sociolegal consequences of reporting positive screening results.

"We propose that primary care clinicians understand their local, state, and national reporting regulations so they know what consequences may or may not accrue to a patient," said Davidson.

She also noted that regulations differ across jurisdictions and that some have mandatory reporting of drug abuse.

However, in general, "asking patients if they have a problem, and connecting them to the treatment they need, results in benefit," she said.

No Teen Screening

The USPSTF did not find enough evidence to be able to assess the benefits and harms of screening for unhealthy drug use in adolescents.

It concluded that for adolescents the evidence is still insufficient, and so the benefits and harms of drug screening in teens can't be determined at this time.

That's not to say that unhealthy drug use among teens is not a major public health problem, said Davidson. Indeed, the evidence review suggests it is one of the most preventable causes of morbidity and mortality for adolescents.

Unfortunately, Davidson said, almost none of the many screening tests the task force examined had been investigated in more than one study, she said.

Nevertheless, she added, this doesn't preclude physicians from asking young patients about drug use.

"We encourage physicians to decide for themselves what is best to do while we call for more research" in this area, said Davidson.

The investigators note that pharmacotherapy, often provided with individual or group counseling, is the standard treatment for opioid use disorders.

Disorders involving use of cannabis, stimulants, and other nonopioid drugs, are usually treated with psychosocial interventions that involve behavioral approaches, including cognitive behavioral therapy.

The investigators also note that managing patients who screen positive for unhealthy drug use is commonly accompanied by other interventions, including testing for blood-borne pathogens; assessment of alcohol and tobacco use, misuse, and dependence; screening for comorbid mental health disorders; and pain assessment in patients abusing opioids.

"It's unclear how often clinicians should screen for unhealthy drug use in adults. This is one of the areas where we have called for further research," said Davidson.

The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF. Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health & Human Services.

JAMA. 2020;323:2301-2309. Full text

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