Lead authors: Jennifer McNeely, MD, MS,1 and Angeline Adam, MD, 1 with the Substance Use Guidelines Committee, October 2020
Successful substance use screening relies on accurate patient self-report. Although urine toxicology, measures of blood alcohol level, or other laboratory testing may detect the presence of substances used very recently, (typically hours or ≤4 days after the last use), these tests are not appropriate for identifying unhealthy use, which may be intermittent and occur over time [Verstraete 2004; Cone and Huestis 2007; Bosker and Huestis 2009]. Laboratory screening tests for alcohol and drugs do not provide information about the severity or consequences of use, and thus provide less information than questionnaires.
There is no reliable biomarker with sufficient sensitivity and specificity to identify the range of drinking behaviors that constitute unhealthy alcohol use [Neumann and Spies 2003; Verstraete 2004; Jatlow, et al. 2014; Stewart, et al. 2014; Afshar, et al. 2017; Jarvis, et al. 2017]. For drug use, urine, saliva, and blood testing are not recommended as replacements for questionnaire-based screening because laboratory tests have a brief window of detection (typically 1 to 4 days) [Verstraete 2004; Cone and Huestis 2007; Bosker and Huestis 2009]. Although hair testing has a more extended detection period, the cost and lack of reliability for detecting occasional drug use decrease its utility in primary care [Verstraete 2004].
|Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults|
|Tool [a], References||Substance(s) Included||No. of Items, Approximate Time Required to Complete, and Format|
AUDIT-C (Alcohol Use Disorders Identification Test–Concise)
|SISQ-Alc (Single-Item Screening Questions for Alcohol)
[Smith, et al. 2009; McNeely, et al. 2015a]
SISQ-Drug (Single-Item Screening Questions for Drug Use)
|Prescription drugs, other drugs|
|SoDU (Screen of Drug Use)
[Tiet, et al. 2015]
|Prescription drugs, other drugs||
|SUBS (Substance Use Brief Screen)
[McNeely and Saitz 2015]
|Tobacco, alcohol, prescription drugs, other drugs||
|TAPS-1 (Tobacco, Alcohol, Prescription Medication, and Other Substance Use)
[Gryczynski, et al. 2017]
|Tobacco, alcohol, prescription drugs, other drugs||
|a. For information on the sensitivity and specificity of tools for drug screening, please see the U.S. Preventive Services Task Force (USPSTF) evidence review Unhealthy Drug Use: Screening; for information on the sensitivity and specificity for alcohol screening, see Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: An Updated Systematic Review for the USPSTF.|
An optimal screening instrument will quickly and accurately identify individuals with the full spectrum of unhealthy use, fit into the existing clinical workflow, and have flexible administration options (i.e., self- or interviewer-administered). To facilitate patient report of substance use, the language used in any screening tool should be clear and nonjudgmental. Drug screening should capture nonmedical prescription drug use and illicit drug use. Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults, above, lists recommended substance use screening tools.
The briefest approach to screening may be to use the Single-Item Screening Questions (SISQ) for alcohol or drug use (SISQ-Alc and -Drug). SISQ tools are validated for interviewer administration or self-administration and have good sensitivity and specificity. A positive response on SISQ tools identifies unhealthy use in the past year but does not indicate the level of risk. Both the Substance Use Brief Screen (SUBS) and the first section of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS-1) tool elicit information about use of tobacco, alcohol, illicit drugs, and nonmedical prescription drugs through a single 4-item instrument. Like the SISQ-Alc and -Drug, the SUBS and TAPS-1 tools screen for any use in the past year, and a positive response indicates unhealthy use but does not identify level of risk.
In some circumstances, the purpose of screening may be to diagnose substance use disorder rather than identify unhealthy drug use. For example, if the clinical setting cannot offer early intervention or preventive care, screening may be used to identify individuals in need of referral to addiction treatment. In such cases, the Screen of Drug Use (SoDU) tool, which specifically identifies drug use disorders, may be used. The SoDU was validated using Diagnostic and Statistical Manual of Mental Disorders–IV (DSM-IV) criteria, and a positive screen corresponds to a DSM-IV diagnosis of “drug abuse or dependence.”
Alcohol: The briefest alcohol screening questionnaires (SISQ-Alc, TAPS-1, SUBS) use a single question about binge drinking in the past year to identify unhealthy alcohol use. Although it is possible for patients to use more alcohol than the recommended limits in the U.S. Department of Health and Human Services and Department of Agriculture Dietary Guidelines (14 drinks/week for men ≤65 years old, 7 drinks/week for women and men ≥65 years old), even in the absence of binge drinking, validation studies have demonstrated good sensitivity [NIAAA 2016; DHHS 2020]. The 3-item Alcohol Use Disorders Identification Test–Concise (AUDIT-C) is a widely used and recommended brief screening tool for alcohol use in medical settings [Bush, et al. 1998; Bradley, et al. 2003; Bradley, et al. 2007; Reinert and Allen 2007; Frank, et al. 2008; Moyer 2013]. Unlike the other brief screening tools, the AUDIT-C identifies the level of risk to patients with problem use and high-risk use. The AUDIT-C does not screen for tobacco or drugs.
Tobacco: Tobacco use is incorporated into some of the brief screening instruments (SUBS, TAPS-1) included in Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults, above. The accuracy of SUBS and TAPS-1 tools for identifying tobacco use is high, with a sensitivity of 98% and a specificity ranging from 80% to 96% [McNeely, et al. 2015b; Gryczynski, et al. 2017]. Use of a single instrument that concurrently screens for tobacco and alcohol use will streamline the screening process.
Drugs: Screening for drug use can be performed with the SISQ-Drug, SUBS, or TAPS-1 tools, all of which perform well in validation studies of adults in primary care settings [McNeely, et al. 2015a; McNeely, et al. 2015b; McNeely, et al. 2016; Gryczynski, et al. 2017]. With changes in the legal status of cannabis and shifting attitudes toward cannabis use, clinics should provide patients and staff with clear instructions about reporting cannabis use on questionnaires that categorize cannabis as an illicit drug [Lapham, et al. 2017]. In states where cannabis is legal, it may be best to ask about its use separately from illicit drugs [Sayre, et al. 2020].
1 Section on Tobacco, Alcohol, and Drug Use, Dept. of Population Health, NYU Grossman School of Medicine, New York, NY
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