Image by Darwin Brandis
Image by Darwin Brandis

Detecting unhealthy drug use

The COVID-19 pandemic and its ensuing isolation and stress have been associated with a sharp increase in substance use as a coping mechanism, as well as drug overdose deaths.

As the COVID-19 pandemic surged in the U.S. last year, so did drug use and overdoses.

In June 2020, 13.3% of nearly 5,500 surveyed U.S. adults reported that they had started or increased substance use in the last 30 days to cope with pandemic-related stress or emotions, according to study results published in August 2020 by MMWR. In many areas, sales of liquor and cannabis also spiked when the pandemic hit, noted Charles Reznikoff, MD, FACP, an addiction medicine subspecialist at Hennepin Healthcare and associate professor of medicine at the University of Minnesota Medical School, both in Minneapolis.

As one might expect, there are also increasing harms of unhealthy drug use (a term that encompasses any use that risks consequences through severe disorders). At least in the U.S., the years-long opioid overdose epidemic may be getting worse, not better. Last December, the CDC alerted clinicians about a concerning acceleration in the increase of already high rates of drug overdose deaths from opioids and psychostimulants such as methamphetamine, with the largest upturn recorded from March to May 2020 as the country implemented stay-at-home orders and other COVID-19 mitigation measures.

“It is very hard to know epidemiologically that COVID or the lockdowns caused it; however, there is a pretty stark coincidence,” Dr. Reznikoff said. “The timing strongly suggests that COVID, the lockdown, or something else that happened because of the lockdown or COVID led to an increase in harm from drug use, such as overdose deaths.”

As the pandemic continues, internists may have an increasingly important role in detecting and preventing harms from unhealthy drug use. In June 2020, the U.S. Preventive Services Task Force (USPSTF) issued a grade B recommendation to screen adults, including pregnant women, for unhealthy drug use in primary care by asking questions (not by testing biological specimens). The statement updated the group's 2008 recommendation, which had concluded there was insufficient evidence to recommend for or against screening for illicit drug use in all age groups.

“Drug use is one of the most common causes of preventable death, injury, and disability in the U.S., so we are recommending that primary care clinicians ask adults about their drug use and connect people who have a problem with drugs to the care they need to get better,” said Karina Davidson, PhD, chair of the Task Force.

The recommendation is particularly relevant for primary care clinicians who have been switching to telemedicine visits, which are conducive to asking screening questions and referring patients to an online treatment program, she added. “This is one of the screening practices that can be implemented remotely,” Dr. Davidson said. “And we know that unhealthy drug use has gone up during this pandemic, so this is a timely screening recommendation for getting patients the help they need.”

Why screen?

Unhealthy drug use is reported by about one in 10 adults older than age 25 years and by about 24% of those ages 18 to 25 years, according to the USPSTF recommendation. The Task Force defined unhealthy drug use as the use of substances (not including alcohol or tobacco products) that are illegally obtained or the nonmedical use of prescription psychoactive medications. It categorized cannabis as an unregulated substance due to varying legality across states. The current evidence was insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents.

In its recommendation statement, the Task Force emphasized that screening for unhealthy drug use in adults should only be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.

“I do feel pretty strongly that any clinician who's in a position to do screening ought to be able to tell the difference between drug use without consequences and drug use disorder, because it's really not that hard to do,” said Richard Saitz, MD, MPH, FACP, professor of medicine and professor and chair of community health sciences at Boston University School of Public Health. “Identifying use is an opportunity for prevention with brief advice, an activity not supported by evidence in the USPSTF review. Identifying drug use disorder is an opportunity to treat or refer for treatment, for which many identified by screening may not be ready, but if they are, it should be done.”

Under the 11 equally weighted DSM-5 criteria for substance use disorder, which include cravings and development of withdrawal symptoms, individuals who report fewer than two symptoms are not considered to have a disorder (even though they may have at least one consequence). Patients with two to three symptoms are considered to have a mild disorder, while four to five symptoms equal a moderate disorder and six or more equal a severe substance use disorder.

For those with substance use disorder, substantially more evidence to support the effectiveness of psychosocial interventions and FDA-approved medications to improve health outcomes has become available since the prior Task Force recommendation. Buprenorphine, methadone, and naltrexone are associated with improved outcomes, such as decreased risk of relapse, in patients with opioid use disorder who seek treatment. (See the November/December 2020 ACP Internist article, “‘Gold standard’ underused for substance misuse” for more about these evidence-based treatments.) In addition, psychosocial interventions like cognitive behavioral therapy and motivational approaches are associated with increased likelihood of abstinence and decreased days of recent drug use compared with control conditions, according to the USPSTF evidence review.

The Task Force found no direct evidence on whether screening itself leads to reduced drug use or drug-related health, social, or legal outcomes. Instead, the group supported its recommendation with more indirect evidence, including the availability of accurate, valid screening tests and the existence of randomized controlled trials of interventions demonstrating improved health outcomes, such as mortality and morbidity, said Dr. Davidson, who is senior vice president of research and dean of academic affairs at the Feinstein Institute for Medical Research at Northwell Health in Manhasset, N.Y.

However, Dr. Saitz wrote in a linked editorial that while screening for drug use is reasonable to consider in clinical practice, screening and brief counseling are not evidence-based methods for improving drug use and its consequences. For example, in 27 trials that tested efficacy of counseling among about 8,700 patients with drug use identified by screening, there were no consistent effects on drug use, on other risky behaviors, or on health, social, or legal outcomes, the USPSTF found.

“I don't think the evidence supports screening for unhealthy drug use to prevent problems or consequences. … And it's not absence of evidence; it's evidence of absent effect,” said Dr. Saitz. “Physicians shouldn't expect changes in drug use when they advise patients identified by screening.”

On the other hand, ACP Member Katharine A. Bradley, MD, MPH, author of another linked editorial accompanying the Task Force recommendation and senior investigator at Kaiser Permanente Washington Health Research Institute in Seattle, said she was satisfied with the screening recommendation despite the indirect evidence supporting it. “From my experience in Kaiser Permanente Washington, I know that screening adds value by bringing awareness of substance use into primary care,” she said.

Dr. Saitz agreed that encouraging more awareness among primary care clinicians is critical. “I don't think that there's basis and evidence to recommend screening for preventive care, yet at the same time, we do need to recognize drug use in our patients and drug use disorder because there are things that we can do about it if and when they're ready to seek help,” he said.

The lack of direct evidence aside, there is still a lot of good that may come from this recommendation, Dr. Saitz added. “This signals to patients that this really is a health issue and that this doctor or clinician wants to talk about it and considers it important. It opens the door for people to have future conversations … which might lower risks of drug use or lead somebody to use less or quit,” he said. “And I don't think you could name a symptom or a sign where knowing the patient's drug use would not be important.”

In addition, the recommendation may spur clinicians to more fully access evidence-based tools for treating and managing substance use disorders, which are currently underused, Dr. Reznikoff said. “It's this vicious cycle of ‘Don't look for it because if you look for it, you won't know what to do about it.’ … We need to break that cycle somehow,” he said. “In one way, a leap of faith to break the Catch-22 was to tell clinicians, ‘Start asking about it,’ which forces clinicians into the uncomfortable situation of ‘Now that I've asked, I've gotten an answer, and the answer forces me to take future steps.’”

For Dr. Davidson, who is also a professor of behavioral medicine at the Zucker School of Medicine at Hofstra University/Northwell Health, the hope is that screening for unhealthy drug use will ultimately lead to more patients receiving effective treatments. “This screening recommendation is really a call for the entire nation to start thinking about having the primary care clinicians, the frontline people, work out the systems, have them in place, and start … using valid questionnaires so that we can get patients into these beneficial treatments,” she said.

As for potential harms of screening for unhealthy drug use, the USPSTF found limited evidence. But as Dr. Saitz wrote in his editorial, “The bounds of magnitude of harm are almost certainly not small.” For anyone, there may be negative implications of having an illegal behavior recorded in the medical record, and for pregnant women in particular, many states consider drug use to be child abuse. “There can be potentially serious consequences to recording this stuff in the records that haven't really been sorted out yet,” Dr. Saitz said.

Implementation tips

For internists who can provide effective diagnosis and treatment or referral for patients with substance use disorders and want to implement this screening recommendation, several validated screeners are available. (See sidebar.) However, the Task Force found insufficient evidence to recommend an optimal time to start asking about unhealthy drug use or an optimal interval for screening.

Clinicians should emphasize to patients that screening for unhealthy drug use isn't mandatory or punitive, or performed via urine or blood testing, said Dr. Davidson. “We want clinicians to be clear. This is offering an opportunity for a patient to answer some questions about their unhealthy drug use to get them the help they need. That makes it voluntary for the person,” she said.

An early adopter of screening for unhealthy drug use was Kaiser Permanente Washington, which rolled it out from 2015 to 2018 as part of whole-person behavioral health screening for unhealthy alcohol use, depression, and suicidality, said Dr. Bradley. From the start, frontline clinicians at three pilot clinics saw value in asking a separate screening question about cannabis use, a practice she advocated in her editorial, since otherwise it may be overlooked.

“[Cannabis use] is so common—somewhere between 18% and 25% of adult patients report use, whereas for other drug use it's 1% to 2%—and the perception of the providers is sometimes, ‘And it's safe,’” Dr. Bradley said. “So frontline clinicians asked us to develop a separate question for cannabis.” (For more on cannabis use, see the Q&A, “Cannabis use increasing among older adults”.)

No one actually asks the questions. Rather, patients fill out the screening tool themselves on paper or on the computer. (This and other approaches are detailed in the National Council for Behavioral Health's 2018 guide on implementing care for alcohol and other drug use in medical settings, for which she and Dr. Saitz served on an expert panel.)

“I think the first key ingredient is to use paper forms because they're easy, unless you have it built into your electronic health record, which most people don't,” said Dr. Bradley, adding that she recommends using screeners that are scaled, meaning that they ask “How often?,” versus those that elicit yes or no answers.

This method of screening is not expensive, she noted. At 25 primary care sites at Kaiser Permanente Washington, the cost of implementing population-based behavioral health screening was $5 per primary care visit with screening annually, according to results published last November by Health Services Research. “Given the value of it, I think everybody has felt that that's worth it,” Dr. Bradley said.

For in-person visits, the staff member who rooms the patient then inputs the data for the clinician. “If it's virtual, it's all there for the provider to see, and they get flagged by the medical assistant about positive results,” she said. “Just like the way we do blood pressure: The primary care provider will circle around, they might ask questions, but they don't gather the data.”

Finally, a positive screen would trigger a symptom assessment with the 11-item DSM-5 checklist for substance use disorder. Dr. Bradley noted that a positive screen for cannabis would trigger the checklist at a higher threshold.

“It would be too big a burden on primary care to give a DSM-5 checklist to every single person who used any cannabis in the past year, but it's appropriate for patients who've used other drugs in the past year, because of their greater risks,” she said.

Historically, primary care has not fully “owned” alcohol and substance use, so staff may view screening as an add-on to their work, she said. To address the new workload, as well as stigma around substance use, practice coaches worked with primary care teams to come up with scripts for conversations, Dr. Bradley said.

“My feeling is physicians can apply what they know about tobacco counseling or counseling for other stigmatized issues, such as mental health, HIV, or sexually transmitted conditions,” she said. “The key is to ask open-ended questions of the patient and use motivational interviewing and shared decision making.”

While Dr. Saitz maintained that the evidence around universal screening is limited, he acknowledged that unhealthy drug use is something clinicians should be alert for, especially during a pandemic when stress or worsening mental health conditions can lead people to use. “You can't tell by looking at somebody whether they are using substances, so you need to find out,” he said.

The best way to find out is to ask, and screening questions provide a good framework for these history-gathering conversations, which are akin to those about over-the-counter medications or complementary therapies, said Dr. Saitz. “I think it is worth everybody knowing what the limitations of the evidence are—but then why we might be asking anyway,” he said.