But screening for unhealthy drug use in adolescents still a non-starter

Primary care physicians should ask healthy adult and adolescent patients about unhealthy drug use, including cannabis, according to the U.S. Preventive Services Task Force (USPSTF).

In a “B” grade recommendation, the task force advised screening for those ages ≥18 years. “Screen when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Screening refers to asking questions about unhealthy drug use, not testing biological specimens,” explained Alex H. Krist, MD, MPH, of Virginia Commonwealth University in Richmond, and co-authors.

Unhealthy drug use was defined as “the use of substances (not including alcohol or tobacco products) that are illegally obtained or the nonmedical use of prescription psychoactive medications,” they stated in JAMA.

The current recommendation is an upgrade and update on one from 2008, when the USPSTF said there was insufficient evidence to green light unhealthy drug use in adults. In this recommendation, the task force maintained the “I” grade for screening for unhealthy drug use in adolescents (ages 12 to 17 years).

“Because of the lack of evidence, the USPSTF concludes that the benefits and harms of screening for any type of unhealthy drug use in adolescents are uncertain and that the balance of benefits and harms cannot be determined,” Krist and co-authors emphasized. That assessment dovetailed with an earlier recommendation, previously reported by BreakingMED, stating that there was still not enough evidence to back-up primary care-based behavioral counseling interventions to keep children (ages ≤11 years) and adolescents off illicit drugs.

Before settling on the new recommendation in adults, the USPSTF commissioned two systematic evidence reviews, one of which focused on “treatment-seeking” patients with known drug use.

It was the latter review that Richard Saitz, MD, MPH, of the Boston University School of Public Health, took issue with in an accompanying editorial.

The inclusion of “patients seeking treatment for drug use is akin to considering studies of chemotherapy for patients seeking care for breast cancer or thrombolysis for symptomatic myocardial infarction as relevant to questions of cancer and cardiovascular disease screening efficacy; efficacious treatment is necessary but not sufficient for making a case for screening. Treatment studies are not sufficient to inform screening because of lead time, length, and other biases and the different nature of an asymptomatic [versus] symptomatic condition,” he stated.

Additionally, “no clinical trials have informed the benefits of screening compared with no screening,” and many published trials on drug treatment were done outside the primary care setting, while others were not able to adequately show “consistent efficacy” of drug treatment, such as counseling, Saitz noted.

While drug-use screening does have some value, he suggested that clinicians focus on treatments for people who seek help, as “most patients with drug use identified by screening already have negative consequences of their use.”

In another accompanying editorial in JAMA Internal Medicine, Katharine A. Bradley, MD, MPH, of the Kaiser Permanente Washington Health Research Institute in Seattle, and co-authors, supported the upgraded recommendation, but pointed out that it includes cannabis use.

However, “33 states have legalized medical use, with 11 of those having legalized recreational use,” which can drive increases in cannabis use and boost the risk for cannabis use disorders, they said, cautioning that “screening questions about unhealthy drug use can be confusing in states where cannabis use is legal… a separate screen for cannabis should be used in states with legalized use.”

Bradley and co-authors also called for “use of self-administered screening… (e.g., paper, tablet, online),” by patients as the latter has shown better results versus verbal screening given by staff; more research on “how to optimally engage patients with DUDs [drug use disorders] in treatment;” and “practical patient-centered systems of care…to increase diagnosis and treatment of DUD.”

Arthur Robin Williams, MD, and Frances R. Levin, MD, both from the Department of Psychiatry, Columbia University, and the New York State Psychiatric Institute, noted that the recommendation to screen for drug use comes with many questions, and they observed that “organized medicine has stuggles with tensions between paternalism, beneficence, and nonmaleficence.” They noted that screening for substance use disorder (SUD) is a far cry from screening for high cholesterol or hypertension: “detection of drug use has led to devastating consequences for some individuals throughout U.S. history.”

And, while they noted that such concerns have been anticipated by the USPSTF, and note that clinicians need to be aware of when it is mandatory to report screening results to authorities, and be aware of the implications — positive and negative of such reporting — Williams and Levin added “Painful stories following detection of drug use are widely documented and more common in certain settings, such as low-income pregnant women of color seeking care in the deep South who have been arrested and had their children taken away for testing positive for cannabis or other drugs.”

The editorialists noted that screening should only be done when a positive result can be effectively managed, with appropriate treatment referral, which the task force underscored in their recommendation.

An unlikely bright spot, Williams and Levin point out, has evolved with the Covid-19 pandemic:

“Under the national emergency, physicians can now treat patients with addiction across most any state line, simply using a telephone,” they wrote. “Previously unimaginable options became available for health care systems to connect with mental health and addiction specialists nationwide… Psychiatrists, mental health clinicians, and administrators more broadly all have an opportunity to contribute and help guide ongoing state and federal reform and should not let the moment pass.”

In aJAMA Patient Page, Jill Jin, MD, MPH, of Northwestern Medicine in Chicago, urged primary care practitioners to go beyond a “simple yes/no question about drug use during wellness visits,” and take a page from clinical studies that employ “more detailed questionnaires,” such as the BSTAD from the Substance Abuse and Mental Health Services Administration, ASSIST from the World Health Organization, and TAPS from the National Institute on Drug Abuse (NIDA).

The evidence report by Carrie D. Patnode, PhD, MPH, of the Kaiser Permanente Evidence-based Practice Center in Portland, Oregon, and co-authors, tested “accuracy studies to detect drug misuse and randomized clinical trials of screening and interventions to reduce drug use.” They included 99 studies (n=84,206), 28 of which addressed drug screening accuracy, done from September 2018 to September 2019.

Patnode’s group found that among adults, the sensitivity of screening tools for detecting unhealthy drug use ranged from 0.71 to 0.94 while the specificity ranged from and 0.87 to 0.97

Interventions to cut drug use were evaluated in 52 trials, and those were primarily looking at psychosocial interventions, which were linked with:

  • Increased likelihood of drug use abstinence: relative risk 1.60 (95% CI 1.24-2.13); absolute risk difference 9% (95% CI 5%-15%).
  • Reduced number of drug use days: mean difference -0.49 day in the last 7 days (95% CI -0.85 to -0.13) versus no psychosocial intervention at 3- to 4-month follow-up.

They also reported that, in treatment-seeking populations, there were ties seen between decreased risk of drug use relapse versus placebo or no medication for:

  • Opioid agonist therapy (such as buprenorphine or methadone): RR, 0.75 (95% CI, 0.59-0.82); ARD -35% (95% CI -67% to -3%).
  • Naltrexone: RR 0.73 (95% CI 0.62-0.85); ARD -18% (95% CI -26% to -10%).

As for intervention harms, the latter were not reported for psychosocial interventions and there were no serious adverse events (SAEs). Also, there was no difference between buprenorphine and placebo for risk of SAEs, such as hospitalizations due to serious medication-related AEs, withdrawal due to AEs, or increased risk of diaphoresis. However, the opioid agonist was associated with increased risk of constipation versus placebo.

Patnode and co-authors highlight that compared with the review done for the 2008 recommendation, there was “substantially more evidence…to support the effectiveness of psychosocial interventions and FDA-approved medications to improve drug use outcomes among persons with unhealthy drug use or a diagnosed drug use disorder.”

But the current reviews had limitations, such as significant variability in patient populations, outcomes, recruitment, and treatment settings for psychosocial interventions; the fact that the accuracy of screening in studies may not apply to all primary care settings; and a primary focus on outcomes such as drug use or retention in treatment versus other clinical, social, and legal outcomes.

Patnode and co-authors confirmed that “single-item drug frequency…can detect unhealthy drug use with reasonable accuracy,” also citing TAPS and the Substance Use Brief Screen.

Krist’s group said more research is needed on the effectiveness of screening and interventions for drug use in adolescents. Also, the optimal screening interval for detecting unhealthy drug use remains unknown. Lastly, more data on “The accuracy of screening tools for detecting nonmedical use of prescription drugs, including opioids” is necessary.

They highlighted that the U.S. Department of Veterans’ Affairs and the American Academy of Family Physicians adopted the 2008 USPSTF recommendation statement. Meanwhile, other groups, such as the American Academy of Pediatrics (AAP) and AAP’s The Bright Futures initiative, do support screening at every physical exam for adolescents through their early 20s for substance use, including tobacco and alcohol.

  1. The U.S. Preventive Services Task Force recommends screening healthy adults about unhealthy drug use through questioning.

  2. Current evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents.

Shalmali Pal, Contributing Writer, BreakingMED™

USPSTF is funded by the Agency for Healthcare Research and Quality (AHRQ). The recommendations and evidence report were funded by AHRQ.

All USPSTF members receive travel reimbursement and an honorarium for participating in USPSTF meetings. One member reported a relationship with Healthwise.

Saitz reported support from, and/or relationships with, the NIH, NIDA, National Institute on Alcohol Abuse and Alcoholism, the Patient-Centered Outcomes Research Institute (PCORI) via Philadelphia College of Osteopathic Medicine, PCORI via Public Health Management, Burroughs Wellcome Fund, McLean Hospital, the American Society of Addiction Medicine, National Council on Behavioral Healthcare, Leed Management Consulting, Kaiser Permanente, UpToDate/Wolters Kluwer, Massachusetts Medical Society, Yale University, Group Health, Charles University, National Committee on Quality Assurance, University of Oregon, Brandeis University, Karolinska Institutet, American Academy of Addiction Psychiatry, Partners, Harvard Medical School, Alkermes, the International Society of Addiction Journal Editors, Springer, the Journal of Addiction Medicine, the Journal of Addictive Diseases and Addiction Science & Clinical Practice, CheckUp & Choices, and ABT, as well as serving as an expert witness in malpractice cases related to alcohol and other drug use disorders.

Patnode reported no relationships relevant to the contents of this paper to disclose. Co-authors reported grants from Oregon Health & Science University and relationships with the American Academy of Addiction Psychiatry.

Jin reported no relationships relevant to the contents of this paper to disclose.

Bradley and a co-author reported grants from NIDA.

Williams reports a grant from National Institute on Drug Abuse during the conduct of the study and personal fees from Ophelia Health outside the submitted work.

Levin reports grants from National Institutes of Health and Substance Abuse and Mental Health Services Administration, grants from National Institute on Drug Abuse (grant K24DA029647), consulting fees from Major League Baseball, nonfinancial support from USWorldMeds, and personal fees from NYS Psychiatric Institute outside the submitted work.

Cat ID: 192

Topic ID: 86,192,286,730,138,192,144,151,925