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. Author manuscript; available in PMC: 2025 Dec 23.
Published before final editing as: J Subst Use Addict Treat. 2025 Aug 8:209780. doi: 10.1016/j.josat.2025.209780

Why is substance use missing from my patient’s problem list? CTN research to advance screening, prevention, and treatment of substance use in primary care

Jennifer McNeely 1, Katharine A Bradley 2, Jane M Liebschutz 3, Geetha A Subramaniam 4
PMCID: PMC12427610  NIHMSID: NIHMS2104963  PMID: 40782845

Abstract

While approximately one in five Americans with substance use disorder (SUD) receives treatment in addiction treatment programs, a majority have seen a primary care medical provider in the past year. Recognizing the critical role of primary care in addressing prevention and treatment of unhealthy substance use, for over a decade the National Drug Abuse Treatment Clinical Trials Network (CTN) has supported research to build the tools and evidence needed to support the integration of SUD care, while remaining realistic about the barriers to doing so. Authored by primary care and addiction medicine physician researchers, this commentary provides an overview of CTN primary care-focused research, from developing and implementing substance use screening tools to advancing evidence-based SUD treatment delivery in primary care settings. We identify three priority areas for research and practice innovations: 1) identifying effective treatment interventions to address polysubstance use; 2) improved screening and treatment for cannabis use; and 3) building the evidence base for substance use interventions among non-treatment seeking patients who have unhealthy drug use identified through screening. Addressing these areas can help primary care fulfill its potential as a key component of the substance use services continuum of care.

Introduction

Approximately one in five Americans with substance use disorder (SUD) receive treatment in addiction treatment programs (Substance Abuse and Mental Health Services Administration, 2023). While there have been major efforts to expand treatment options – particularly for opioid use disorder – this striking treatment gap remains (Gilbert et al., 2022; Jones et al., 2023; Substance Abuse and Mental Health Services Administration, 2023). At the same time, 85% of adult Americans have had a doctor’s visit in the past year, with 79% having a wellness visit in primary care (National Center for Health Statistics, 2023). Despite the high rate of visits, individuals with SUD or hazardous alcohol or drug use may receive treatment for a range of medical and mental health conditions in primary care, but rarely for substance use (Hallgren et al., 2020; IOM, 2006; Rieckmann et al., 2016; Williams et al., 2017).

Clearly, primary care could play a key role in the prevention and treatment of SUD. Unhealthy substance use impacts many - if not all - of the medical conditions that are routinely managed by primary care providers, who have an opportunity to address it as part of patient-centered care and in the context of an established patient-provider relationship. However, primary care is already overburdened. A single primary care provider would have to spend over 8 hours each day just to deliver the preventive care recommended by the United States Preventive Services Task Force (USPSTF) to an average size patient panel (Privett & Guerrier, 2021). In reality, within a typical 10–15 minute primary care visit there is little time to address anything but the most pressing acute complaints and chronic conditions. Burnout and workforce shortages were problematic prior to 2020 (Clifton et al., 2021), and have only worsened since the COVID-19 pandemic (Gerteis et al.). In 2024, 64% of surveyed primary care providers endorsed the statement that ‘primary care is crumbling’, and 76% reported that their clinic was not fully staffed (Quick COVID-19 Primary Care Survey, 2024). In fact, fewer physician trainees plan to enter primary care specialties than ever in years past (Paralkar et al., 2023).

Recognizing the critical role of primary care in addressing prevention and treatment of unhealthy substance use, for over a decade the National Drug Abuse Treatment Clinical Trials Network (CTN) has supported research to build the tools and evidence needed to support providers in delivering SUD care, while remaining realistic about the barriers to doing so. This commentary provides an overview of CTN studies in this area, along with recommended next steps for building the evidence base for integrating substance use services in primary care.

Studies in the NIDA Clinical Trials Network

Screening Tools

Early on, CTN recognized that the lack of an efficient drug screening and assessment tool was a barrier to identifying unhealthy drug use in medical settings. Drug screening can be complex, since it involves multiple substances that can vary widely in their patterns of use, routes of administration, and level of risk. Screening and assessment tools that provide all of the information needed to guide clinical interventions were far too lengthy for screening all patients in primary care settings (Humeniuk et al., 2006; McNeely et al., 2015). Furthermore, most screening tools were limited to a single substance (i.e. alcohol or tobacco only), which could further hinder adoption into practice. In response, CTN conducted several studies, all of which are now completed, to validate screening tools and inform their implementation.

In 2014 CTN launched a study (CTN-0059) to develop a brief 2-stage screening and assessment instrument - the Tobacco, Alcohol, Prescription Medication, and Other Substances (TAPS) Tool - and validate it in a sample of 2,000 adult primary care patients (McNeely et al., 2016; Wu et al., 2016). The TAPS Tool accurately identifies unhealthy use of eight specific substance classes, requires a median time of 2–4 minutes to complete, and can be administered by clinical staff or self-administered by patients to facilitate a variety of workflows (Adam et al., 2019; McNeely et al., 2016).

Subsequent CTN studies (CTN-0062 and -0062A1) examined the implementation and feasibility of integrating screening into the electronic health record (EHR) and delivering it as part of routine primary care. Across 3 health systems, 9 clinics implemented EHR-integrated screening and achieved high screening rates (72% overall) (McNeely et al., 2021; McNeely et al., 2023). These studies also identified barriers to screening, including concerns about confidentiality and stigmatization among patients, and deficits in knowledge, time, and lack of prioritization of substance use among providers (McNeely et al., 2018). While the study was successful in its primary objective of integrating screening into primary care, primary care providers rarely used an EHR-integrated brief intervention script to counsel patients who were identified as having unhealthy alcohol or drug use (McNeely et al., 2021; McNeely et al., 2023). Feedback from primary care providers and staff indicated that low adoption of counseling was driven by relatively low rates of screen-positive patients, clinical workflows, and lack of knowledge and comfort (Moore et al., 2021).

Another practical approach to drug and alcohol screening is to integrate it with other routine screening workflows, such as screening for tobacco or mental health (Sayre et al., 2020). In the Kaiser Permanente Washington system, patients self-administer a single-item screening question for cannabis and previously validated screens for alcohol and other drugs (Smith et al., 2010), alongside depression screening (Glass et al., 2018). A CTN study (CTN-0077) conducted in this system validated the single-item cannabis screen (Matson et al., 2022), and demonstrated the discriminative validity of the Checklist for cannabis use disorder in patients with daily cannabis use (Hamilton et al., 2024). Another CTN study (CTN-0065) showed that implementation of this screening system in a 3-clinic pilot was associated with increased diagnosis of cannabis use disorder (Richards et al., 2019).

Implementation of cannabis screening revealed that in Washington, where all cannabis use is legal, 19.1% of primary care patients reported cannabis use (3.9% daily) and 1.7% reported other substance use (Sayre et al., 2020). Notably, among primary care patients who reported past-year cannabis use, 68% explicitly reported medical cannabis use, but 90% reported health reasons for use (implicit medical use); only 8% had medical cannabis use documented in the electronic health record (Lapham et al., 2022). While the prevalence (21%) of any cannabis use disorder did not differ based on whether cannabis was used for medical reasons or not, the prevalence of moderate to severe cannabis use disorder was significantly lower for those with medical use only (1%) compared to those with nonmedical use, alone or with medical use (7–8%) (Lapham et al., 2023).

More recent CTN research extended this line of research to examine the psychometric performance of the DSM-5 Substance Use Symptom Checklist, including for assessment of OUD. CTN-0113 demonstrated the psychometric validity of the Checklist in an observational study of primary care patients (Hallgren et al., 2024; Matson et al., 2023), and supported its use to measure DSM-5 symptoms in patients with OUD or long term opioid treatment documented (Williams et al., 2024).

Evidence from screening tool validation studies contributed to a new recommendation by the USPSTF to screen adults for drug use in primary care settings ‘when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred’ (Grade B recommendation) (USPSTF, 2020). The guideline remains controversial because of weak evidence supporting evidence-based interventions for unhealthy drug use in primary care in patients who are identified through screening (i.e. not ‘treatment-seeking’) (Bradley et al., 2020; Chou et al., 2020; Saitz, 2020). Brief interventions for drug use have a mixed – and largely null – evidence base (Gelberg et al., 2015; Humeniuk et al., 2012; Roy-Byrne et al., 2014; Saitz et al., 2014). While effective treatment for some types of drug use disorders can be delivered in primary care, these have not been tested in non-treatment seeking patients identified by screening (Patnode et al., 2020; Saitz, 2020). Subsequent work in the CTN has sought to target this evidence gap.

Substance use treatment interventions in primary care

Primary care practices are challenged to integrate substance use treatment to primary care when they are already overburdened. Team-based care models, which bring resources into the clinic to directly assist providers in delivering evidence-based treatment, are a promising approach. Collaborative care models have been effective for other behavioral health conditions, and have been broadly adopted as a strategy for improving the reach and quality of depression treatment in primary care (Coventry et al., 2014; Gilbody et al., 2006; Katon et al., 2010; Thota et al., 2012; Wagner, 1998). But these models are rarely used for substance use interventions, and their effectiveness for increasing evidence-based care for SUD remains unproven (Bradley et al., 2018; Oslin et al., 2014; Saitz et al., 2013; Watkins et al., 2017).

Based on the early promise of a nurse care manager model for increasing the delivery of medication for OUD in primary care (LaBelle et al., 2016), the Primary Care Opioid Use Disorder Treatment Trial (PROUD, CTN-0074) tested this approach in a 6-site implementation-effectiveness trial and found that it was effective overall for bringing new patients into office-based MOUD treatment (Campbell et al., 2021; Lapham et al., 2024). However, the model was not successful in all health systems. Three years after hiring of nurses began, the nurse care manager intervention had increased OUD medication treatment in 4 of 6 health systems. Factors that appeared most important for success were broad support for the nurse care manager within primary care, and lack of easy access to medications for OUD nearby in the community (Matson et al., 2025).

Patients are willing to engage with substance use interventions offered in primary care, yet potent barriers remain. Patients with opioid misuse have complex medical and mental health comorbidities that can compete with prioritization of substance use, for both the patient and their primary care providers. These co-occurring problems may be improved by team-based care, as is currently being tested in multiple trials conducted within the Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR) network (Reducing Opioid-Related Harms to Treat Chronic Pain), and in four HEAL-funded trials of collaborative care for patients with opioid and mental health disorders (DeBar et al., 2023; Fortney et al., 2024; Harris et al., 2021; Meredith et al., 2021).

Two recent CTN trials examine the efficacy of collaborative care models for substance use, which provide an on-site nurse care manager and remote health coaches offering additional behavioral interventions to adult primary care patients. The Subthreshold OUD Prevention (STOP) trial (CTN-0101) specifically targeted patients with risky opioid use who do not have a moderate-severe OUD, with a primary objective of decreasing days of risky opioid use, results forthcoming (Liebschutz et al., 2023). The recently initiated Collaborative Care for Polysubstance use in Primary Care Settings (Co-Care) study (CTN-0139, CT.gov NCT06116266) utilizes an adapted collaborative care model for patients with moderate-severe SUD and polysubstance use. While polysubstance use can refer to a broad range of substance use patterns (Bunting et al., 2024), for the purpose of this trial polysubstance use disorder is defined as moderate-severe opioid, stimulant, and/or alcohol use disorder, with current unhealthy use of at least two of these substances. The Co-Care intervention seeks to engage patients where they are already receiving medical care (in primary care) and delivers evidence-based treatment for SUD – specifically medications for opioid and alcohol use disorder, and contingency management for stimulant use disorder.

While there has been progress, stigma and lack of knowledge about SUD remains pervasive among patients and primary care providers and contributes to a feedback loop that keeps SUD treatment marginalized because it is unfamiliar, and unfamiliar because it is marginalized. Structural barriers, including regulations and health insurance organizational models that split behavioral health care from other health care, reinforce this marginalization. Ultimately, this cycle can only be broken by making SUD treatment part of routine medical care through addressing knowledge, payment and regulatory environments, stigma, and the need for more treatment options in primary care.

Next steps

From our perspectives as primary care and addiction medicine physicians and addiction researchers, we see three priority areas to address so that primary care can fulfill its potential in the substance use services continuum of care.

First, additional research on polysubstance use treatment interventions is needed. Polysubstance use is common among primary care patients with substance use disorders (Wu et al., 2017). Some progress has been made toward treating OUD with medications in primary care, though access to office-based medications remains inadequate (in the case of buprenorphine and naltrexone), or prohibited (in the case of methadone). A current CTN trial (CTN-0131, CT.gov NCT06323824) will provide needed evidence on office-based methadone treatment. Yet pragmatic and effective approaches to treating disorders involving stimulants, benzodiazepines, inhalants, and other non-opioid drugs are lacking (Bernstein et al., 2021; Substance Abuse and Mental Health Services Administration, 2023; Tilhou et al., 2024). The Co-Care trial (CTN-0139) is one study that seeks to integrate evidence-based treatment for multiple substances (opioid, stimulant, alcohol use disorders), but more work is needed to fully understand polysubstance use patterns and optimal treatment approaches.

Second, we need improved screening approaches and treatment interventions to address cannabis use. Cannabis, which is now legal for medical and recreational use in 24 states and Washington, DC, is the most commonly used drug (excluding alcohol) by primary care patients and in the general population (McNeely et al., 2021; McNeely et al., 2016; Substance Abuse and Mental Health Services Administration, 2023), with a large population burden of substance use disorder symptoms (Compton et al., 2016; Matson et al., 2021; McNeely et al., 2023). Despite the prevalence of cannabis use disorder among people who use cannabis regularly it is not perceived to be as harmful as other drugs, and federal funding for research on cannabis use lags far behind its impact on the population. Most of the currently validated drug screening instruments, including the TAPS Tool, group cannabis with illegal drugs (Matson et al., 2022; McNeely et al., 2016; Patnode et al., 2020). This is confusing and stigmatizing for patients and may lead to inaccurate screening results. Adaptation of the TAPS Tool would allow patients to report cannabis use separately from other drugs. Importantly, we need effective approaches to treating cannabis use disorder given its impacts on health and functioning. Because most patients with unhealthy cannabis use will not seek care in specialized addiction treatment programs (Substance Abuse and Mental Health Services Administration, 2023), cannabis use disorder treatment development should focus on interventions that are feasible to deliver in primary care settings, including medications and behavioral interventions that can be adopted and sustained with fidelity.

Third, it is imperative to close the evidence gap identified by USPSTF for interventions to address unhealthy drug use in patients identified through screening who are not seeking SUD treatment (Patnode et al., 2020). In contrast to the robust evidence supporting screening and brief intervention and care management for unhealthy alcohol use in primary care (Kaner et al., 2018; O’Donnell et al., 2014; O’Connor et al., 2018), there have been few studies of primary care interventions for non-treatment seeking patients with unhealthy drug use. People with SUD are far more likely to have a primary care visit than to present at an addiction treatment program (Satre et al., 2020; Substance Abuse and Mental Health Services Administration, 2023), and these primary care visits are a unique opportunity to engage patients in making changes to their substance use in the context of an established longitudinal relationship with their medical providers. A handful of studies is not sufficient to promote or dismiss the treatment of SUD in primary care (Bradley et al., 2020; Saitz, 2020), and we eagerly await the findings from new trials, including the Co-Care Trial (CTN-0139), and others that are proactively engaging primary care patients with alcohol (Bonar et al., 2024) and opioid use disorders (DeBar et al., 2023; Fortney et al., 2024; Harris et al., 2021; Meredith et al., 2021).

Conclusion

Until recently, substance use was primarily viewed as a personal or moral failing and not a medical condition, and the process of fully integrating care for SUD into health care is only partially accomplished (IOM, 2006; U.S. DHHS, Office of the Surgeon General, 2016). We must continue to conduct science that is on par with rigorous research on other common medical conditions. Moreover, we should stop considering SUD identified in primary care as a binary condition. For cardiovascular disease, or even its risk factors (i.e. diabetes, hypertension, hypercholesterolemia), it would be unthinkable to test the same treatment in people irrespective of the severity of the disease. People with mild substance use disorders likely respond to different interventions than those with severe substance use disorders, and likewise for cannabis use versus stimulant or opioid use disorders. In addition, this research needs to be conducted in vulnerable populations that are often impacted more severely by SUD, such as those receiving primary care at Federally Qualified Health Centers.

Finally, while conducting studies addressing any of these areas, it is imperative to think about implementation simultaneously, so that interventions that are demonstrated to be effective can be rapidly implemented in practice, as is the case in many of the CTN studies noted above. Primary care is a key partner in improving the health of people who use drugs, but it will only happen once we design and show the effectiveness of thoughtful models of practice that bring resources into primary care, instead of continuing to ask them to do more with less.

Highlights.

  • Primary care has a key role to play in the substance use services continuum of care

  • Advances in screening and treatment support the integration of substance use services

  • Priority areas for future research and practice innovations are identified

  • Approaches should focus on polysubstance and cannabis use, which are prevalent

  • Evidence-based interventions to engage non-treatment seeking patients are needed

Acknowledgments

Disclaimers:

Dr. Geetha Subramaniam is an employee of the National Institute on Drug Abuse (NIDA), and she was substantially involved in some of the cited studies, consistent with her role as NIDA Scientific Officer on National Institute on Drug Abuse (NIDA) grant numbers: UG1DA013035, UG1DA040314, and UG1DA049436. This manuscript reflects the views of the authors and may not reflect the opinions, views, and official policy or position of the U.S. Department of Health and Human Services or any of its affiliated institutions or agencies.

Work on this manuscript was supported by the National Institute On Drug Abuse of the National Institutes of Health under Award Numbers UG1DA013035, UG1DA040314, and UG1DA049436. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conflict of Interest Disclosures:

Dr. Jennifer McNeely is a consultant for Eli Lilly and Company

Dr. Jane Liebschutz is a consultant for Biomotivate, Inc.

Declaration of interests

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Nothing to report: Dr. Katharine A. Bradley, Dr. Geetha Subramaniam

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributor Information

Jennifer McNeely, New York University Grossman School of Medicine, Dept. of Population Health and Dept. of Medicine, Division of General Internal Medicine and Clinical Innovation, NIDA Clinical Trials Network New York Node, 180 Madison Ave., New York, NY 10016.

Katharine A. Bradley, Senior Investigator, Kaiser Permanente Washington Health Research Institute, Affiliate Professor, Department of Medicine and Health Systems and Population Health, University of Washington, NIDA Clinical Trials Network Health Systems Node, 1730 Minor Ave, Suite 1360, Seattle, WA 98101

Jane M. Liebschutz, Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh, UPMC, Pittsburgh, PA 15213.

Geetha A. Subramaniam, Center for Clinical Trials Network, National Institute on Drug Abuse, North Bethesda, MD 20852

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