Unhealthy drug use: How to screen, when to intervene

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Applied Evidence

Unhealthy drug use: How to screen, when to intervene

J Fam Pract. 2014 September;63(9):524-530

Aleksandra Zgierska, MD, PhD

Iliya Paul Amaza, MD, MPH

Richard L. Brown, MD, MPH

Marlon Mundt, PhD

Michael F. Fleming, MD, MPH

Recognizing and helping patients at risk for a substance use disorder doesn’t have to be time-consuming. Here’s how to make screening and implementing a brief intervention a routine part of care.

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References

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13. Otto C, Crackau B, Löhrmann I, et al. Brief intervention in general hospital for problematic prescription drug use: 12-month outcome. Drug Alcohol Depend. 2009;105:221-226.

14. Humeniuk R, Ali R, Babor T, et al. A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries. Addiction. 2012;107:957-966.

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17. Roy-Byrne P, Bumgardner K, Krupski A, et al. Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial. JAMA. 2014;312(5):492-501.

18. Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280-295.

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36. Centers for Medicare & Medicaid Services. Screening, Brief Intervention, and Referral to Treatment (SBIRT) services. Centers for Medicare & Medicaid Services Web site. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/sbirt_factsheet_icn904084.pdf. Accessed March 4, 2014.

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PRACTICE RECOMMENDATIONS

› Implement screening and brief intervention (SBI) for unhealthy drug use among adults in primary care. C
› Consult the National Institute on Drug Abuse’s Screening for Drug Use in General Medical Settings Resource Guide for step-by-step recommendations for implementing a drug SBI. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › Joe M, age 54, comes to your office for his annual physical examination. As part of your routine screening, you ask him, “In the past year, how often have you used alcohol, tobacco, prescription drugs for nonmedical reasons, or illegal drugs?” Mr. M replies that he does not use tobacco and has not used prescription drugs for nonmedical reasons, but drinks alcohol weekly and uses cannabis and cocaine monthly.

If Mr. M were your patient, what would your next steps be?

One promising approach to alleviate substance use problems is screening and brief intervention (SBI), and—when appropriate—referral to an addiction treatment program. With strong evidence of efficacy, alcohol and tobacco SBIs have become recommended “usual” care for adults in primary care settings.^1,2 Strategies for applying SBI to unhealthy drug use (“drug” SBI) in primary care have been a natural extension of the evidence that supports alcohol and tobacco SBIs.

Screening for unhealthy drug use consists of a quick risk appraisal, typically via a brief questionnaire.^3-5 Patients with a positive screen then receive a more detailed assessment to estimate the extent of their substance use and severity of its consequences. If appropriate, this is followed with a brief intervention (BI), which is a time-limited, patient-centered counseling session designed to reduce substance use and/or related harm.^4-6

So how can you make use of a drug SBI in your office setting?

Drug screening: What the evidence says

Screen patients by asking, "In the past year, how often have you used alcohol, tobacco, prescription drugs for nonmedical reasons, or illegal drugs?"Currently, evidence on drug SBI is limited. The US Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against universal drug SBI.^4,7,8 The scarcity of validated screening and assessment tools that are brief enough to be used in primary care, patients’ use of multiple drugs, and confidentiality concerns likely contribute to the relative lack of research in this area.^3,6,9

To our knowledge, results of only 5 randomized controlled trials (RCTs) of drug SBI that included universal screening have been published in English. Here is what these researchers found:

Bernstein et al¹⁰ investigated the efficacy of SBI for cocaine and heroin use among 23,699 adults in urgent care, women’s health, and homeless clinic settings. They randomized 1175 patients who screened positive on the Drug Abuse Screening Test¹¹ to receive a single BI session or a handout. At 6 months, patients in the BI group were 1.5 times more likely than controls to be abstinent from cocaine (22% vs 17%; P=.045) and heroin (40% vs 31%; P=.050).

Zahradnik et al¹² examined the efficacy of SBI in reducing the use of potentially addictive prescription drugs by hospitalized patients. After researchers screened 6000 inpatients, 126 patients who used, abused, or were dependent on prescription medications were randomized to receive 2 BI sessions or an information booklet. At 3 months, 52% of patients in the BI group had a ≥25% reduction in their daily doses of prescription drugs, compared to 30% in the control group (P=.017),¹²However, this difference was not maintained at 12 months.¹³

Humeniuk et al¹⁴ evaluated the efficacy of SBI among primary care patients ages 16 to 62 years in Australia, Brazil, India, and the United States who used cannabis, cocaine, amphetamines, or opioids. Patients were screened and assessed using the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).¹⁵ Patients whose scores indicated they had a moderate risk for problem use (N=731) were randomly assigned to receive a BI or usual care. At 3 months, patients in the BI group reported a reduction in total score for “illicit substance involvement” compared to controls (P<.001). However, country-specific analyses found that BI did not have a statistically significant effect on drug use by those in the United States (N=218), possibly due to protocol differences and a greater exposure to previous substance use treatment among US patients.¹⁴

Despite limited evidence, multiple professional organizations, including the AAFP, support routine implementation of drug screening and brief intervention in primary care. Saitz et al¹⁶ investigated the efficacy of drug SBI among primary care patients (N=528) who had been screened using the ASSIST. The most commonly used drugs were marijuana (63% of patients), cocaine (19%), and opioids (17%). Patients were randomly assigned to a 10- to 15-minute BI, a 30- to 45-minute intervention, or no intervention. BI did not show efficacy for decreasing drug use at 6-month follow-up.