Substance use and pain
The evaluation of alcohol and drug use is an integral part of assessing risky health behaviors. The 10-item Alcohol Use Disorder Identification Test (AUDIT) is a self-report tool developed by the World Health Organization.23,24 Validated in medical settings, scores of 8 or higher suggest problematic drinking.25,26 The AUDIT has demonstrated high specificity (94%) and moderate sensitivity (81%) in primary care settings.27 The AUDIT-C (items 1, 2, and 3 of the AUDIT) has also demonstrated comparable sensitivity, although slightly lower specificity, than the full AUDIT, suggesting that this 3-question screen can also be used in primary care settings.27
Opioid medications, frequently prescribed for chronic pain, present serious risks for many patients. The Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R) is a 24-item self-reporting scale that can be completed in approximately 10 minutes.28 A score of 18 or higher has identified 81% of patients at high risk for opioid misuse in a clinical setting, with moderate specificity (68%). Although other factors should be considered when assessing risk of opioid misuse, the SOAPP-R is a helpful and quick addition to an opioid risk assessment.
The CRAFFT Screening Tool for Adolescent Substance Use is administered by the clinician for youths ages 14 to 21. The first 3 questions ask about use of alcohol, marijuana, or other substances during the past 12 months. What follows are questions related to the young person’s specific experiences with substances in relation to Cars, Relaxation, being Alone, Forgetting, Family/Friends, and Trouble (CRAFFT). The CRAFFT has shown moderate sensitivity (76%) and good specificity (94%) for identifying any problem with substance use.29 These measures may be administered to clarify or confirm substance use patterns (ie, duration, frequency), or to determine the severity of problems related to substance use (ie, social or legal problems).
Trauma and PTSD
Approximately 7.7 million adults per year will experience posttraumatic stress disorder (PTSD) symptoms, although PTSD can affect individuals of any age.30 Given the impact that trauma can have, assess for PTSD in patients who have a history of trauma or who otherwise seem to be at risk. The Post-traumatic Stress Disorder Checklist (PCL-5) is a 20-item self-report questionnaire that screens for symptoms directly from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for PTSD. One limitation is that the questionnaire is only validated for adults ages 18 years or older. Completion of the PCL-5 takes 5 to 10 minutes. The PCL-5 has strong internal consistency reliability (94%) and test-retest reliability (82%).31 With a cutoff score of 33 or higher, the sensitivity and specificity have been shown to be moderately high (74.5% and 70.6%, respectively).32
The Child and Adolescent Trauma Screen (CATS) is used to assess for potentially traumatic events and PTSD symptoms in children and adolescents. These symptoms are based on the DSM-5, and therefore the CATS can act as a useful diagnostic aid. The CATS is also available in Spanish, with both caregiver-report (for children ages 3-6 years or 7-17 years) and self-report (for ages 7-17 years) versions. Practical use of the PCL-5 and the CATS involves screening for PTSD symptoms, supporting a provisional diagnosis of PTSD, and monitoring PTSD symptom changes during and after treatment.
Memory and cognition
Cognitive screening is a first step in evaluating possible dementia and other neuropsychological disorders. The importance of brief cognitive screening in primary care cannot be understated, especially for an aging patient population. Although the Mini Mental Status Exam (MMSE) has been widely used among health care providers and researchers, we recommend the Montreal Cognitive Assessment (MoCA).
The MoCA is a simple, standalone cognitive screening tool validated for adults ages 55 to 85 years.33 The MoCA addresses many important cognitive domains, fits on one page, and can be administered by a trained provider in 10 minutes. Research also suggests that it has strong test-retest reliability and positive and negative predictive values for mild cognitive impairment and Alzheimer dementia, and it has been found to be more sensitive than the MMSE.34 We additionally recommend the MoCA as it measures several cognitive skills that are not addressed on the MMSE, including verbal fluency and abstraction.34 Scores below 25 are suggestive of cognitive impairment and should lead to a referral for neuropsychological testing.
The MoCA’s sensitivity for detecting cognitive impairment is high (94%), and specificity is low (42%).35 To ensure consistency and accuracy in administering the MoCA, certification is now required via an online training program through www.mocatest.org.
Adapting these screening tools to practice
These tools are not meant to be used at every appointment. Every practice is different, and each clinic or physician can tailor the use of these screening tools to the needs of the patient population, as concerns arise, or in collaboration with other providers. Additionally, these screening tools can be used in both integrated care and in private practice, to prompt a more thorough assessment or to aid in—and inform—treatment. Although some physicians choose to administer certain screening tools at each clinic visit, knowing about the availability of other tools can be useful in assessing various issues. The FIGURE can be used to aid in the clinical decision-making process.
