One Screening Question to Help Identify Drug Use
One Screening Question to Help Identify Drug Use
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV. Dr. Gupta reports no financial relationship to this field of study.
Synopsis: In a sample of patients from primary care practice, a single screening question accurately identified drug use.
Source: Smith PC, et al. A single-question screening test for drug use in primary care. Arch Intern Med 2010;170:1155-1160.
Although substance abuse is common both in the general population and in those with medical illnesses, there remains a gap between the gamut of addictive diseases and physicians' ability to recognize such in a busy primary care practice.1 For instance, in one study it was revealed that approximately half of patients who have substance abuse serious enough to prompt a presentation for treatment stated that the physician who cared for them was unaware of their substance abuse problem. Most of the patients were not presenting for the first time for substance abuse treatment, yet they did not believe that their physicians were aware of their substance abuse.1 Studies have also demonstrated that physicians' level of knowledge, attitudes, and skills concerning issues important to patients with substance abuse all play a role in the failure to identify and address the problems of patients with alcoholism and other drug abuse.2
Knowing that primary care interventions by physicians play a significant role in addressing this issue, an easy and convenient method to recognize such patients would go a long way in reducing such disparities in our communities. Even when patients are on medications such as opioids, studies have demonstrated that some physicians are confident that they can identify individuals who are vulnerable to problematic drug behaviors; however, empirical evidence regarding these "gut feelings" has shown otherwise.3 Therefore, while we can all appreciate the significance of appropriately identifying drug abuse in a primary care practice, when it comes to asking the right question, there is no consensus.
In their study, Smith et al recruited 394 adult patients from an urban safety-net hospital-based primary care clinic at an academic medical center. These patients were asked a single screening question, "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" A response of at least 1 time was considered positive for drug use. Following the single drug screening question, the 10-item Drug Abuse Screening Test (DAST-10) was administered for comparison. The reference standard was the presence or absence of current (past year) drug use or a drug use disorder (abuse or dependence) as determined by a standardized diagnostic interview. Drug use was also determined by oral fluid testing for common drugs of abuse. After a statistical analysis was conducted, the authors found that this single screening question was 100% sensitive (95% confidence interval [CI], 90.6%-100%), and 73.5% specific (95% CI, 67.7%-78.6%) for the detection of a drug use disorder. However, it was not as sensitive for the detection of self-reported current drug use (92.9%) and drug use detected by oral fluid testing or self-reports (81.8%).
Commentary
While drug use is prevalent in primary care, detecting so commonly is not. Several common barriers exist and may include lack of time in a busy practice setting, insufficient training to manage a positive screen, need to triage competing problems, lack of treatment resources, unfamiliarity with screening tools, and parents unwilling to provide privacy in case of adolescents.4 Therefore, successful screening and brief interventions often require a quick screen question the physician can easily administer. While such a screening question may not be useful in every practice, being aware of it can have a dramatic impact on many practices, especially in those areas where drug or substance abuse may be identified as an issue but is not necessarily being actively addressed. For example, my state of West Virginia ranks No. 1 in the nation for the incidence of acute hepatitis B cases per 100,000 population.5 Injection drug use (IDU) is a major mechanism of transmission of the disease, which is preventable by proper vaccination. Vaccination is recommended for high-risk individuals including those with IDU. Therefore, the single screening question would go far in helping identify and vaccinate those at risk for acute hepatitis B, thereby bringing the rates down in the state.
I believe that due to the sheer nature of the volume of responsibilities laid down for the primary care physician, the good old days of asking 10 or 20 questions to identify one disease process are quickly coming to an end. Soon, the single-question screen will become a standard for many illnesses and our patients will be asked several such pertinent questions to rule out a broad spectrum of disorders. Therefore, for my patients, this quick and single screening question will become an important tool in my arsenal for rapidly identifying the issue of drug abuse when suspected. This question will go great with another one I often ask to screen for depression in my patients: What do you do for fun?
References
1. Saitz R, et al. Physician unawareness of serious substance abuse. Am J Drug Alcohol Abuse 1997;23:343-354.
2. Bradley KA. The primary care practitioner's role in the prevention and management of alcohol problems. Alcohol Health & Research World 1992;18:97-104.
3. Wasan AD, et al. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain 2007;23:307-315.
4. Van Hook S, et al. The "Six T's": Barriers to screening teens for substance abuse in primary care. J Adolesc Health 2007;40:456-461.
5. Daniels D, et al. Surveillance for acute viral hepatitis United States, 2007. MMWR Surveill Summ 2009;58:1-27. Available at: www.cdc.gov/mmwr/PDF/ss/ss5803.pdf. Accessed July 29, 2010.
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