A first: U.S. panel recommends screening adults for drug use

Excerpted from STAT By Brittany Flaherty

As new ways to identify and treat people who use opioids and other drugs emerge, an independent panel of experts is recommending that health care providers screen their adult patients for illicit drug use.

The U.S. Preventive Services Task Force has determined, for the first time, that there is enough evidence to state with “moderate certainty” that screening adults for illicit substance use is overall beneficial.

What the panel means by “screening” means a physician asking a patient a series of questions. The answers can indicate who might need to be offered or referred support. It does not include drug testing. “Screening tools are not meant to diagnose drug dependence, abuse, addiction, or use disorders,” the members of the task force wrote in their report.

“We have a pretty high prevalence of adults using illicit drugs and we’re seeing harms every day from that,” said task force member Dr. Carol Mangione, the chief of general internal medicine at the David Geffen School of Medicine at UCLA. “This is a big change that we’re really excited about. Effective treatment is where we will finally begin to move the needle on the epidemic.”

Currently in draft form, the new recommendation will be comment through Sept. 9. After the task force reviews comments, it will issue a final recommendation.

The task force defined illicit drug use as both taking illicit drugs and using prescription drugs for nonmedical purposes — meaning for reasons, durations, frequencies, or in amounts other than prescribed.

In 2008, the task force, which advises the federal government and makes recommendations for primary care providers, concluded that there was not enough evidence to recommend for or against screening in adults or adolescents. But after reviewing recent studies, it determined there are adequate tools available and enough care systems in place to recommend screening in adults, which can help doctors identify patients who may need support.

The availability of new studies, tools, and treatments is due in part to recognition of the need for ways to address the opioid epidemic, said Dr. Gary LeRoy, president-elect of the American Academy of Family Physicians (AAFP).

“As we move forward as a society, we are learning more,” he said. “Since 2008, opioid and substance use disorders have become a national epidemic. It’s on everybody’s consciousness right now as health care professionals.”

In 2017, more than 70,000 Americans died from drug overdoses.

In terms of treatment, it found that three drugs approved by the Food and Drug Administration — naltrexone, buprenorphine, and methadone — can help adults with opioid use disorder reduce relapses and stick with treatment. The task force also found that psychosocial interventions like behavioral therapy can help adults avoid or reduce their use of illicit drugs, particularly cannabis.

The recommendation does not extend to adolescents aged 12 to 17 years. Mangione said this should not be confused as a recommendation against screening in this age group; rather the panel did not have enough information to assess whether screening tools and interventions are effective and safe for teenagers. Due to concerns about the effects of long-term buprenorphine use on the developing brain, this drug, for example, is approved only for ages 16 years or older. The panel called for more studies to fill this research gap.

The recommendation is not mandatory for clinicians, nor does it endorse one screening tool or intervention. It is up to primary care providers, hospital systems, and medical organizations to decide whether and how to implement drug screening, Mangione said.

Some medical organizations, like the American College of Physicians, which represents internists, and the AAFP have their own recommendations about clinical care. While neither would comment directly on the draft recommendations, LeRoy said many physicians are likely already on the lookout for signs of drug use but may not always be using a tool.

“We may not be checking boxes on a screen, but we’re mentally checking boxes saying something is wrong,” he said.

LeRoy said continuity of care and understanding family dynamics sometimes help family physicians and other providers clue into changes that could indicate illicit drug use.

“For some of these folks, we have literally watched them grow up,” he said. “So, we’ve watched how they behaved and how they did in school as an adolescent. And then it’s just like, OK, something’s wrong. Let’s have a discussion here.”

One challenge, he added, is that there are many constraints on physicians’ time and many topics to cover in visits.

“Primary care providers are very, very busy individuals,” he said. “It would be nice in a perfect world to sit down and do all the screens for everything under the sun on our patients. But you find what you what works within your practice.”

Dr. Holly Biola, chief of family medicine at the Lincoln Community Health Center in Durham, N.C., said there could be cultural and language barriers to using some tools, noting that it’s not uncommon for her to encounter six different languages in a single day.

“That is not to say we shouldn’t be screening all adults for illicit substances. I think we should,” Biola said. “I just worry about the logistics of it and about finding the right tool for my patients.”

The draft statement does stipulate that screening is recommended “when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.” In some clinics and health centers, Mangione said, there aren’t enough services available to diagnose and treat patients after screening indicates they need help.

“If you offer screening and find people with serious problems but you have no ability to get them to treatment, then you haven’t helped them much,” she said.

LeRoy agreed, noting that access to resources, financial challenges, and transportation to health care services can all present hurdles. He also said it’s important to have care on site if possible because when people leave, “sometimes you don’t see them back. They just disappear.”

Despite potential challenges in implementation, the new recommendation is important given current substance use issues across the country, Mangione said. “I think in the context of the opioid epidemic, most primary care providers would welcome the recommendation.”