The Perils of Screening for Unhealthy Drug Use Are a Call to Action for the Mental Health Workforce

The US Preventive Services Task Force (USPSTF) updated their recommendations¹ and evidence report and systematic review² regarding screening for unhealthy drug use. They now recommend clinicians screen all populations of adults, including pregnant women, in primary care settings for unhealthy drug use who do not currently have a substance use disorder (SUD) diagnosis or receive addiction treatment.² The recommendation, with a grade B (screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred), is an update to its 2008 inconclusive guidance on the relative benefits and harms for adults. However, the USPSTF maintained its inconclusive recommendation for adolescents given a lack of high-quality evidence (I statement).

Screening for unhealthy drug use among adults raises many questions. From its inception, organized medicine has struggled with tensions between paternalism, beneficence, and nonmaleficence. Unlike screening for high cholesterol or elevated blood pressure levels, detection of drug use has led to devastating consequences for some individuals throughout US history. The USPSTF anticipates such concerns and has added language that it is important for clinicians to be aware of mandatory “reporting of screening results to medicolegal authorities and understand the positive and negative implications of reporting.”³ Painful stories following detection of drug use are widely documented and more common in certain settings, such as low-income pregnant women of color seeking care in the deep South who have been arrested and had their children taken away for testing positive for cannabis or other drugs.⁴

With growing awareness of these risks, there are currently efforts in some states such as New York to require written informed consent from patients before performing drug testing. Correctly, the USPSTF emphasizes screening tools that do not include drug testing. The USPSTF conducted a systematic review and identified 30 different screening tools, often with a sensitivity of more than 75% for detecting unhealthy drug use, and report that most studies used structured clinical or diagnostic interviews rather than biologic reference standards such as testing of hair or urine specimens.²

Verbal (or questionnaire-based) screening for drug use has been supported by the Substance Abuse and Mental Health Services Administration throughout the past decade and can be performed quickly. The most notable framework, Screening, Brief Intervention, and Referral to Treatment, has a growing empirical evidence base for positive outcomes but is mostly limited to patients with nicotine use disorder or heavy drinking who are excluded under the current USPSTF recommendation, which specifically regards unhealthy drugs. Evidence has remained limited for the Screening, Brief Intervention, and Referral to Treatment framework to improve outcomes among patients with unhealthy drug use or SUDs.⁵ This likely reflects the superiority of brief interventions (typically 5–15 minutes consisting of motivational interviewing and cognitive behavioral therapy techniques) for affecting alcohol consumption and nicotine quit date success rather than drug use.

As with any screen, a screen for unhealthy drug use should only be performed when clinical management can be effectively tailored in response to a positive screen result. Thus, the USPSTF states that screening should only occur “when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred.”¹ Among patients with a positive screen result for unhealthy drug use, a subset will meet criteria for moderate or severe SUDs and warrant referral to treatment. Unfortunately, there is widespread misunderstanding among clinicians about what should be considered as evidence-based treatment for addiction and its effectiveness. Some clinicians in primary care settings persist in believing addiction cannot be treated and is a personal choice or moral failing.⁶ Often, patients who are determined to need addiction treatment, such as those presenting intoxicated to the emergency department, are given lists of nearby Alcoholics Anonymous meetings and sent on their way. While Alcoholics Anonymous may be useful for some individuals with alcohol use disorder,⁷ peer recovery without professional care is typically insufficient for stabilizing more severe SUDs, most notably opioid use disorder. Regardless, data from the National Survey on Drug Use and Health suggest peer recovery is the most common form of treatment respondents meeting criteria for SUDs report receiving in the past year.⁸

These realities reflect just how poorly equipped our health care system is for diagnosing and treating SUDs. Long bifurcated, settings for general health care and mental health are rarely co-located and typically have poor referral networks. Still today, many mental health care settings further screen out patients with active substance use, challenging integrated care models.⁹ As a result, care is delivered in siloes and rarely coordinated or comprehensive. Yet comorbidity is the rule, not the exception. The USPSTF rightly emphasizes that there are several well-characterized risk factors for unhealthy drug use among adults in addition to age (18 to 25 years) and sex (male); having a mental health condition, such as posttraumatic stress disorder, mood disorder, or nicotine or alcohol dependence; a history of physical or sexual abuse, interpersonal violence, parental neglect, or other adversity in childhood; and a family history of SUDs. These risk factors should be highly familiar to all mental health clinicians. If widespread screening for unhealthy drug use commences in primary care settings, it may also lead to widespread detection of mental illness, trauma, and abuse of all kinds. Many primary care clinicians may struggle to identify mental health and addiction specialists, especially who participate in the same insurance networks.

Unfortunately, the USPSTF found that the balance of benefits and harms could not be determined regarding screening among adolescents. This is of particular concern because SUDs are increasingly understood to be much like other developmental disorders, often originating among individuals in their teen years or even earlier. Further, these younger populations arguably stand the most to gain by early intervention, similar to how the field now recognizes prodromal psychosis and the importance of comprehensive services to thwart possible progression to schizophrenia. In part, it seems the USP-STF based this recommendation on inadequate evidence of the effectiveness of treatment, whether pharmacologic or psychotherapeutic, for adolescent populations with SUDs. Adolescents with SUDs do not necessarily respond to the same treatment modalities as adults,¹⁰ and this finding by the USPSTF underscores the need for more research on how to effectively engage these populations. While most adults, roughly 90%, with SUDs go without care, the numbers for adolescents are even more concerning. Multiple studies have determined less than 5% of adolescents with opioid use disorder receive timely medication treatment,¹¹ such as buprenorphine or methadone, long the gold standard of care reflecting many barriers that have not been satisfactorily addressed.¹² While our treatment systems often fail adults, they have largely abandoned adolescents with addiction to wilderness camps and juvenile justice.

Rather than despair, our nation’s sweeping response to the coronavirus disease 2019 (COVID-19) pandemic throughout recent months offers several lessons for how we can rapidly scale access to comprehensive and coordinated care for patients with SUDs, adults and adolescents alike, in primary care settings. Under the national emergency, physicians can now treat patients with addiction across most any state line, simply using a telephone. Previously unimaginable options became available for health care systems to connect with mental health and addiction specialists nationwide. These innovations will help us determine which regulations are obsolete and which should return, modified for our new normal. Psychiatrists, mental health clinicians, and administrators more broadly all have an opportunity to contribute and help guide ongoing state and federal reform and should not let the moment pass.