A national expert task force has issued new guidance on screening for unhealthy drug use in adult patients.
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
https://www.medscape.com/viewarticle/932016#vp_1
