Unhealthy Drug Use: Screening --Adults age 18 years or older


General

Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. Screening should be implemented 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.)

Frequency of Service

Screening should be implemented 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.)

Risk Factor Information

These include being aged 18 to 25 years; male sex; having a mental health condition, personality or mood disorder, or nicotine or alcohol dependence; a history of physical or sexual abuse, parental neglect, or other adversity in childhood; or drug or alcohol addiction in a first-degree relative.1,9 Factors associated with misuse of prescription drugs include history of other drug use, mental illness, pain, and greater access to prescription drugs.10 Factors associated with prenatal use of drugs include a mental health disorder, interpersonal violence, and family history of substance use.11


Clinical

Practice

Patient Population Under Consideration

This recommendation statement applies to adults 18 years or older, including pregnant and postpartum persons, and adolescents aged 12 to 17 years in primary care settings. This statement does not apply to adolescents or adults who have a currently diagnosed drug use disorder or are currently undergoing or have been referred for drug use treatment. This statement applies to settings and populations for which services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. The net benefit assessment does not apply to settings and populations for which treatment cannot be provided or the result of screening is punitive.

Definitions

For the purposes of this recommendation, “unhealthy drug use” is defined as the use of substances (not including alcohol or tobacco products) that are illegally obtained or the nonmedical use of prescription psychoactive medications; that is, use of medications for reasons, for duration, in amounts, or with frequency other than prescribed or by persons other than the prescribed individual. These substances are ingested, inhaled, injected, or administered using other methods to affect cognition, affect, or other mental processes; to “get high”; or for other nonmedical reasons. Unhealthy drug use is abbreviated as “drug use” in this recommendation statement.Screening refers to asking 1 or more questions about drug use or drug-related risks in face-to-face, print, or audiovisual format. It does not refer to testing urine, saliva, blood, or other biological specimens for the presence of drugs.

Assessment of Risk

The USPSTF recommends screening by asking questions in all adults 18 years or older regardless of risk factors for unhealthy drug use. However, some factors are associated with a higher prevalence of unhealthy drug use. These include being aged 18 to 25 years; male sex; having a mental health condition, personality or mood disorder, or nicotine or alcohol dependence; a history of physical or sexual abuse, parental neglect, or other adversity in childhood; or drug or alcohol addiction in a first-degree relative.1,9 Factors associated with misuse of prescription drugs include history of other drug use, mental illness, pain, and greater access to prescription drugs.10 Factors associated with prenatal use of drugs include a mental health disorder, interpersonal violence, and family history of substance use.11

Screening Tools

Several screening tools that ask questions about drug use are available for identifying 1 or more classes of unhealthy drug use, the frequency or severity of use, or drug-related health, social, or legal consequences that characterize unhealthy use or drug use disorders. Interviewer-administered tools and self-administered tools appear to have similar accuracy.12Primary care practices may consider several factors when selecting screening tools. Brief tools (eg, NIDA [National Institute on Drug Abuse] Quick Screen, which asks 4 questions about use of alcohol, tobacco, nonmedical use of prescription drugs, and illegal drugs in the past year) may be more feasible in busy primary care settings, but longer tools (eg, the 8-item ASSIST [Alcohol, Smoking and Substance Involvement Screening Test]) that assess risks associated with unhealthy drug use or comorbid conditions may reveal information signaling the need for prompt diagnostic assessment. Tools with questions about nonmedical use of prescription drugs (eg, TAPS [Tobacco, Alcohol, Prescription Medication, and Other Substance Use]) may be useful when clinicians are concerned about prescription misuse. One study reported that drug use questions in the PRO (Prenatal Risk Overview) risk assessment tool were reasonably accurate for identifying drug abuse or dependence in pregnant women.Screening tools are not meant to diagnose drug dependence, abuse, addiction, or drug use disorders. Patients with positive screening results may, therefore, need to be offered or referred for diagnostic assessment.

Screening Intervals

There is little evidence about the optimal time to start asking about unhealthy drug use or the optimal interval for screening in adults older than 18 years.

Treatment

Treatment of drug use disorders is based on the type of drug used, the severity of drug use, and the type of use disorder. Many drug use disorders are chronic, relapsing conditions, and many persons who start treatment do not complete treatment.13 Therefore, treatment must often be repeated to stabilize current drug use, reduce relapse, and achieve abstinence or other treatment goals. Some patients, such as those who are pregnant, nursing, or caring for ill or healthy neonates, may require specialized treatment settings.Pharmacotherapy, which is often provided with individual or group counseling, is the standard for treatment of opioid use disorders involving heroin or prescription opioid use in adults and pregnant and postpartum persons.14-16 Drug use disorders involving nonopioid drugs, such as cannabis, stimulants, and some prescription drugs, are generally treated with various psychosocial interventions that usually involve multiple sessions of cognitive behavioral therapy, motivational interventions, contingency management, relapse prevention, community reinforcement, family behavioral therapy, 12-step facilitation therapy, or other behavioral approaches. Intensive interventions usually involve several in-person sessions over several weeks or months.The management of patients who screen positive is usually accompanied by other interventions, including testing for blood-borne pathogens; assessment of misuse of, abuse of, or dependence on alcohol or tobacco; assessment of potentially coexisting mental health disorders; and pain management for patients with pain who are abusing opioids.

Implementation

In practice, the benefits and harms of screening may vary because of several health, social, and legal issues. In many communities, affordable, accessible, and timely services for diagnostic assessment and treatment of patients with positive screening results are in limited supply or unaffordable.To minimize the potential adverse effects such as stigma, labeling, or medicolegal consequences of asking questions about drug use and documenting and reporting answers, clinicians should be aware of state requirements and best practices on informed consent for screening, mandatory screening, documenting screening results in medical records, reporting of screening results to medicolegal authorities, and confidentiality protections (see the Additional Tools and Resources section).17-24 This recommendation statement applies to settings and populations for which services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. The net benefit assessment does not apply to settings and populations for which treatment is not provided or the result of screening is punitive.

Additional Tools and Resources

Several tools may help clinicians implement this screening recommendation (Box).

Suggestions for Practice Regarding the I Statement for Adolescents Aged 12 to 17 Years

Potential Preventable Burden

Based on a national survey in 2018, 8% of adolescents aged 12 to 17 years reported drug use in the last month. Among youth reporting such drug use, the most commonly used substances were marijuana, inhalants, prescription psychotherapeutic drugs, opioids, and hallucinogens.1 An estimated 2.7% met diagnostic criteria for drug dependence or abuse,1 and the vast majority presented with concurrent mental health diagnoses.25 Risk factors for drug use in youth include aggressive childhood behavior, lack of parental supervision, poor social skills, access to drugs at school, and community poverty.26Adolescent substance use, including use of heroin and misuse of prescription opioids, is associated with the leading causes of death—suicide, overdose, unintentional injury, and violence in adolescents and young adulthood.25 Substance use during this period of rapid brain development can also harm neurocognitive development and endocrine function that, in turn, can impair academic, occupational, and social functioning.26-28 Adolescents with drug use disorders are also at increased risk of sexually transmitted infections, other physical health problems, unintended pregnancies, criminal involvement, and school truancy.25

Potential Harms of Screening and Treatment

Although there is limited evidence on harms, adolescents may experience potential harms from screening for drug use such as labeling and stigmatization. Because of concerns about long-term use of opioid agonists, the US Food and Drug Administration (FDA) restricts approval for buprenorphine to youth 16 years or older, and the US Department of Health and Human Services restricts admission to methadone programs to youth younger than 18 years who continue to use opioids after at least 2 rounds of detoxification and psychosocial interventions.28

Current Practice

About 50% to 86% of pediatricians report routinely screening for substance use, and most screen using their clinical impressions rather than a validated screening tool.22

Other Related USPSTF Recommendations

The USPSTF has issued recommendation statements on these related topics:

  • Interventions to prevent drug use in children, adolescents, and young adults29
  • Screening and behavioral counseling interventions for reducing unhealthy alcohol use in adolescents and adults30
  • Interventions for tobacco smoking cessation in adults, including pregnant women31
  • Primary care interventions to prevent tobacco use in children and adolescents32
  • Screening for depression in adults33
  • Screening for depression in children and adolescents34
  • Screening35

This recommendation statement replaces the 2008 USPSTF recommendation, which 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 those who were pregnant or postpartum.36 This updated statement incorporates new evidence since 2008 about the accuracy of screening tools and the benefits and harms of treatment of unhealthy drug use or drug use disorders. This new evidence supports the current recommendation that primary care clinicians offer screening to adults 18 years or older, including those who are pregnant or postpartum, when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. The USPSTF continues to conclude that the evidence is insufficient to assess the balance of benefits and harms of screening for drug use in adolescents.


Rationale

AssessmentImportanceUnhealthy Drug Use: Screening | Recommendation | United States Preventive Services Taskforce

Many people in the US experience problems related to unhealthy drug use, defined in this recommendation statement as the use of illegal drugs and the nonmedical use of prescription psychoactive medications (ie, use of medications for reasons, for duration, in amounts, or with frequency other than prescribed or use by persons other than the prescribed individual). In 2018, an estimated 12% of US residents 18 years or older reported current unhealthy drug use in a national survey.1 Unhealthy drug use is more commonly reported by young adults aged 18 to 25 years (24%) than by older adults (10%) or adolescents aged 12 to 17 years (8%). In 2018, an estimated 5.4% of pregnant persons aged 15 to 44 years reported unhealthy drug use in the last month. Adults 18 years or older (10.5%) and adolescents aged 12 to 17 years (8.0%) more commonly reported cannabis use in the last month than nonmedical use of psychotherapeutic medications, including pain relievers (2.1% and 1.3%, respectively) and opioids (1.2% and 0.7%, respectively).1 In both age groups, less than 1% reported use of heroin, cocaine, hallucinogens, inhalants, or methamphetamines in the last month.An estimated 8 million persons 12 years or older met diagnostic criteria for drug dependence or abuse of drugs in the past year.1 Drug use is one of the most common causes of preventable death, injuries, and disability.2,3 In 2017, unhealthy drug use caused more than 70,000 fatal overdoses.4 Drug use can cause many serious health effects that vary by drug type, administration mode, amount, and frequency of use, as well as pregnancy status.5 Opioid use can cause drowsiness, slowed breathing, constipation, coma, and fatal overdose. Stimulants such as cocaine can cause arrhythmias, myocardial infarction, seizures, and other complications. Marijuana use is associated with slowed reaction time; problems with balance, coordination, learning, and memory; and chronic cough and frequent respiratory infections.5 Injection drug use may result in blood-borne viral and bacterial infections.2,5 Drug use during pregnancy can increase risk of obstetric complications such as placental abruption, preeclampsia, and third trimester bleeding, as well as adverse fetal and infant outcomes such as spontaneous abortion, abnormal brain growth, preterm delivery, low birth weight, and neonatal abstinence syndrome.6 Drug use is also associated with violence, criminal activity, incarceration, impaired school and work performance, interpersonal dysfunction, and other social and legal problems.7

Magnitude of Net BenefitUnhealthy Drug Use: Screening | Recommendation | United States Preventive Services Taskforce

Adults 18 Years or Older

The USPSTF concludes with moderate certainty that screening by asking questions about unhealthy drug use in adults has moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred.

Adolescents Aged 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.See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.8


Others

No information available.


Tools

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