Screening

Screening, brief intervention, and referral to treatment (SBIRT) for alcohol use disorders in primary care has been well studied and is recommended for incorporation into routine primary care by the U.S. Preventive Services Task Force (USP-STF, SOR B). However, SBIRT in primary care for drug use has been less studied to date, and USPSTF states that there is currently insufficient evidence to recommend for or against routine screening for drug use in primary care.

With the recent increase in prescription drug misuse and abuse, interest in drug-use SBIRT incorporation into primary care has broadened and is being studied for efficacy (Insight Project, 2009). Limitations on drug-use SBIRT in primary

Table 51-2 CRAFFT Screening Tool for Adolescents Table 51-3 CAGE-AID Screening Tool for Adults

CRAFFT

Question

Car

Have you ever ridden in a car by someone (including yourself) who was "high" or had been using alcohol or drugs?

Relax

Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?

Alone

Do you ever use alcohol or drugs while you are by yourself, or alone?

Forget

Do you ever forget things you did while using alcohol or drugs?

Friends

Do family members or friends ever tell you that you should cut down on your drinking or drug use?

Trouble

Have you ever gotten into trouble while you were using alcohol or drugs?

Scoring:

A "no" response = 0 points; a "yes" response = 1 point. 0-1 point = negative screen.

2-6 points = positive screen; consider a safety contract for "yes" response to "car" question regardless of total score.

CAGE

Question

Cut down

Have you felt you ought to cut down on your drinking or drug use?

Annoyed

Have people annoyed you by criticizing your drinking or drug use?

Guilty

Have you felt bad or guilty about your drinking or drug use?

E ye opener

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Scoring:

A "no" response = 0 points; a "yes" response = 1 point. 0-1 point = negative screen. 2-4 points = positive screen.

care include lower prevalence of drug use in primary care patients compared with alcohol use as well as concerns about the practicality of use and positive predictive value (PPV) of available screening instruments in the primary care setting. The American Academy of Pediatrics (AAP), the Bright Future Initiative, and American Medical Association (AMA) Guidelines for Adolescent Preventative Services (GAPS) all recommend at least annual screening of adolescents for drug use. The American College of Obstetricians and Gynecologists (ACOG) advocates regular, periodic screening for all patients, regardless of pregnancy status, although no specific screening instrument is recommended and, to date, no screening instrument has been validated for pregnant women (Lanier and Ko, 2008). Common validated screening instruments for drug use are briefly discussed below.

The CRAFFT is the only screening instrument validated for adolescents and has shown an 83% PPV (Table 51-2). It screens for alcohol as well as drug use (Knight et al., 2002).

The ASSIST, CAGE-AID, and DAST have been validated in nonpregnant adults. PPVs for the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) are not currently available (Newcombe et al., 2005). It screens for tobacco and alcohol in addition to drugs. The ASSIST is available at no cost from the World Health Organization (WHO).

The CAGE-Adjusted to Include Drugs (CAGE-AID) has shown 12% to 78% PPV, with PPV increasing with increasing prevalence of drug use in the study population (Brown and Rounds, 1995). It screens for both alcohol and drug use (Table 51-3).

The Drug Abuse Screening Test (DAST) has similarly shown a wide PPV range of 23% to 75% and is also in the public domain. It screens for drug use only (Staley and El-Guebaly, 1990).

The ASSIST and DAST are more lengthy screens than the CAGE-AID and CRAFFT and consequently have not been reproduced here. The SAMHSA SBIRT initiative recommends both

Box 51-2 FRAMES intervention technique

Feedback about personal risk Responsibility of the patient for change Advice to change Menu of strategies Empathy: express empathy.

Self-efficacy: elicit and support patient's self-efficacy for change.

Box 51-3 Five "A's" Intervention Technique

Assess the risk of the behavior for the patient. Advise the patient on their risk and how to modify. Agree: come to an agreement with patient on treatment. Assist the patient with the treatment plan. Arrange follow-up or referral to treatment.

the ASSIST and the DAST for drug screening. (Lanier and Ko, 2008). SBIRT models vary but typically involve a brief screen of several questions regarding tobacco, alcohol, and/or drug use, conducted by frontline staff. Recently a single-question screen for drug use has been validated for primary care: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" An answer of one or more is a positive screening response (Smith et al., 2010). With sensitivity of 100% and specificity of 73.5%, this single-question screen is comparable to the four-question CAGE-AID.

Patients screening positive receive more in-depth screening with a self-administered or provider-administered screening instrument, such as the DAST or ASSIST, which both allow for stratification of each patient along the SUD continuum. The physician then scores the formal screen and reviews the results with the patient. Patients screening negative are given brief feedback about the results of their screen, and their healthy choices regarding substance use are reinforced by the physician. Patients screening positive for at-risk use, but who do not meet criteria for abuse or dependence, receive a brief intervention, often using the FRAMES model (Box 51-2) or the "Five A's" model (Box 51-3). Both are useful for patients receptive to change. Motivational interviewing techniques may be more useful than the FRAMES or Five A's techniques for patients who are more ambivalent about change (Searight, 2009).

Patients screening positive and meeting criteria for abuse or dependence are offered referral to onsite or, more typically, community drug treatment programs. Referral to treatment can be time-consuming and therefore is often done by ancillary staff with knowledge of local treatment resources, or by referring the patient to a community-based agency that provides treatment-matching services.

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