https://acpinternist.org/weekly/archives/2020/06/16/4.htm

USPSTF recommends screening for unhealthy drug use in adults

This new statement replaces the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation, which concluded that the evidence at that time was insufficient to assess the balance of benefits and harms of screening.


The U.S. Preventive Services Task Force recommends screening adults by asking questions about unhealthy drug use (B recommendation) when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.

The recommendation statement was published June 9 by JAMA, along with an accompanying systematic review and evidence report. The Task Force identified 30 screening tools that have been evaluated in adults, pregnant or postpartum patients, or adolescents. Many tools had a sensitivity of 75% or more for detecting unhealthy drug use, drug abuse or dependence, or drug use disorders.

Primary care practices may consider several factors when selecting screening tools, the Task Force said. For example, brief tools such as the National Institute on Drug Abuse Quick Screen, which asks four questions about use of alcohol, tobacco, nonmedical use of prescription drugs, and illegal drugs in the past year, may be more feasible, it stated. Longer tools, such as the eight-item Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), that assess risks associated with unhealthy drug use or comorbid conditions may uncover information that signals a need for prompt diagnostic assessment. Tools with questions about nonmedical use of prescription drugs, such as Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS), may be useful when clinicians are concerned about prescription misuse, the Task Force said.

There is little evidence available about the optimal time to start asking about unhealthy drug use or the optimal interval for screening in adults, according to the recommendation. Because of relapse, treatment must often be repeated to achieve abstinence, it noted. Pharmacotherapy, along with counseling, is the standard for opioid use disorders involving heroin or prescription opioid use. Drug use disorders involving nonopioid drugs, such as cannabis, stimulants, and some prescription drugs, can be treated with psychosocial interventions of cognitive behavioral therapy, motivational interventions, 12-step programs, or other behavioral approaches, the Task Force said.

This recommendation statement replaces the 2008 Task Force recommendation, which concluded that the evidence at that time was insufficient to assess the balance of benefits and harms of screening. The recommendation does not apply to adolescents or adults who have a currently diagnosed drug use disorder or are currently undergoing or have been referred for drug use treatment.

An accompanying editorial offered several cautions. Given that any evidence for efficacy is limited to individuals seeking treatment, screening becomes less relevant, and clinicians should focus on treatments for those seeking help, according to the editorial. Also, because cannabis is not a main contributor to morbidity and mortality from drug use, questions regarding how to screen become important. Most current screening tools capture and do not distinguish medical cannabis use from recreational use, and there has been little study of risky use thresholds to apply in clinical practice, the editorial said.

“Screening for drug use is reasonable to consider in clinical practice, but it is not evidence-based for improving health,” the editorial concluded. “These observations should serve as an important call for the development and study of new strategies to identify and address drug use in ways that can reduce related harms of such use.”