USPSTF Recommends Screening Adults for Illicit Drug Use

On Aug. 13, the U.S. Preventive Services Task Force posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on screening for illicit drug use, including nonmedical use of prescription drugs, in adults and adolescents. The USPSTF also posted a separate draft evidence review(www.uspreventiveservicestaskforce.org) on interventions for drug use.

Based on the evidence, the recommendations varied by age group. The USPSTF recommended screening for illicit drug use in adults 18 or older, with the stipulation that screening should be implemented when services for accurate diagnosis, effective treatment and appropriate care can be offered or referred — a “B” recommendation.(www.uspreventiveservicestaskforce.org)

“Illicit drug use can have a devastating impact on individuals and families,” said task force chair Karina Davidson, Ph.D., M.A.Sc., in a news release.(www.uspreventiveservicestaskforce.org) “Clinicians can help by screening their adult patients and connecting people who use illicit drugs to the care they need to get better.”

The USPSTF also concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening in adolescents, and issued an “I” recommendation for that population.

“We want to help prevent illicit drug use in teens, so we’re calling for more research on the benefits of screening,” added task force member Carol Mangione, M.D., M.S.P.H. “Clinicians should continue to use their professional judgment to determine what’s best for their teen patients.”

The draft recommendation statement updates the USPSTF’s 2008 “I” recommendation(www.uspreventiveservicestaskforce.org) for screening adolescents, adults and pregnant women for illicit drug use, which the AAFP supported at that time.

The new draft recommendation includes new evidence on the accuracy of screening tools and additional information on the benefits and harms of treatment in adults. The draft also highlights the importance of having systems in place to help people who use illicit drugs find proper care.

Draft Recommendation Highlights

The 2008 recommendation concluded that the evidence at that time was insufficient to assess the balance of benefits and harms of screening for illicit drug use in adolescents and adults, including pregnant women.

The USPSTF commissioned two systematic evidence reviews to update the 2008 recommendation, examining evidence on the accuracy and harms of screening for illicit drug use as well as the benefits and harms of pharmacotherapy for opioid use disorders and psychosocial interventions for any type of illicit drug use.

The task force reviewed 12 studies that assessed the accuracy of 15 different screening tools in nonpregnant adults. Several tools directly addressed the frequency of drug use or the frequency of drug use and associated risks, while one tool indirectly assessed illicit drug use.

Screening tools reviewed by the task force included the

• Substance Use Brief Screen;
• Tobacco, Alcohol, Prescription Medication and Other Substance Use (TAPS);
• TAPS-1;
• Alcohol, Smoking and Substance Involvement Screening Test (ASSIST);
• ASSIST-Drug;
• Cannabis Abuse Screening Test;
• Drug-Abuse Screening Test (2-, 10- and 28-question versions);
• Prescription Drug Use Questionnaire-Patient Version;
• Parent Screening Questionnaire;
• Screen of Drug Use; and
• Two-Item Conjoint Screen.

Screening tools had higher sensitivity for detecting unhealthy use and drug use disorders related to “any drug,” cannabis, heroin and stimulants than for nonmedical use of prescription opioids or sedatives.

Four studies assessed the accuracy of direct or indirect tools in detecting illicit drug use or drug use disorders in women recruited during prenatal care visits or shortly after delivery. Prevalence of drug use across these studies ranged from 1.2% to 41%.

The task force reported limited evidence on the accuracy of screening tools in adolescents. Most studies focused on detection of cannabis use, and no studies provided specific information on opioid use or other drug classes.

No studies directly addressed the benefits of screening on reducing illicit drug use or drug-related health, social or legal outcomes in any population.

Regarding pharmacotherapy, several trials reported that use of FDA-approved treatments were beneficial for nonpregnant adults with opioid use disorders. Adults assigned to pharmacotherapy generally had lower relapse rates and increased retention rates in treatment than adults assigned to placebo or no treatment.

The task force also reviewed several studies on psychosocial interventions to reduce illicit drug use. In adults, these interventions were associated with a 60% increased likelihood of abstinence from drug use at 3 to 4 months postintervention, and a 52% increased likelihood of abstinence at up to 12 months postintervention.

Five trials specifically assessed brief or intensive psychosocial interventions in pregnant or postpartum women. None reported significant effects on illicit drug use or other outcomes at 3 to 6 months postintervention.

Few trials on psychosocial interventions focused on adolescents. In those trials, the task force reported that the evidence was limited and the results were inconclusive.

Overall, the USPSTF concluded with moderate certainty that screening for illicit drug use in adults has a moderate net benefit when the appropriate services for diagnosis, treatment and care can be offered or referred, but found a lack of evidence regarding such screening in adolescents.

Family Physician Expert Perspective

David O’Gurek, M.D., a former chair of the AAFP Commission on Health of the Public and Science who practices in Philadelphia, told AAFP News that understanding the importance of the screening recommendation being changed from “I” to “B” “relies on an understanding of what it is and what it isn’t.” He emphasized that the recommendation does not refer to screening for diagnosis of substance use disorder but for illicit drug use, which may or may not be associated with a diagnosis of SUD.

O’Gurek said family physicians can play a key role in identifying illicit substance use and differentiating it from dependence and SUD. “As community physicians, they can serve as partners in public health to understand the patterns within their communities surrounding illicit substance use,” he said.

O’Gurek added that current limits in social determinants of health funding and referral mechanisms make it difficult for FPs to fully provide appropriate care and treatment for patients with illicit substance use or SUD, but FPs can look at the recommendation as an opportunity to take charge of the issue and push for changes at a systemic level.

“Family physicians truly understand the social conditions in which their patients are born, live, work and grow, and can be leaders in ensuring that system changes occur to be able to implement screening with the appropriate resources available to all patients who desire services,” he said.

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