What is the recommended approach for screening for substance misuse?

Screening for Substance Misuse

Use a single-question screen asking "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" as your initial screening tool, which demonstrates 90-100% sensitivity and 74% specificity for substance use disorders. 1

Initial Screening Approach

Primary Screening Tools

For rapid universal screening in primary care, implement one of these validated approaches:

• Single-question screen: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" (If clarification needed: "For instance, because of the experience or feeling it caused.") Any response of 1 or more times is a positive screen. 1

• Alternative single-question approach: "How many days in the past 12 months have you used drugs other than alcohol?" A response of 7 or more days meets screening criteria (100% sensitivity, 93.73% specificity for drug use disorders). 2

• CAGE-AID: Adapts the CAGE questions to include drugs, demonstrating higher sensitivity than CAGE alone for substance abuse, particularly effective across varying sex, income, and education levels. 3

Secondary Screening for Positive Results

If the single-question screen is positive, administer the Drug Abuse Screening Test-10 (DAST-10) to quantify risk level: 1

The DAST-10 scoring system stratifies patients as follows:

• 0 points = low risk: Reinforce healthy behavior 1
• 1-3 points = moderate risk: Monitor and reassess patient 1
• >3 points = substance abuse or dependence: Proceed to full assessment 1

The DAST-10 demonstrates 90-100% sensitivity and 77% specificity for substance use disorders. 1

Risk Stratification After Positive Screen

Stratify positive screens into three categories to guide intervention intensity: 1

Hazardous Use

• Infrequent use with potential health consequences, risk of dependence, or legal repercussions 1
• Intervention: Brief counseling using motivational interviewing approach, ongoing assessment 1

Substance Abuse

• One or more of the following within 12 months: 1
  • Recurrent use causing failure to fulfill major role obligations (work, school, home)
  • Recurrent use in physically hazardous situations
  • Recurrent substance-related legal problems
  • Continued use despite persistent social/interpersonal problems
• Intervention: Brief counseling, negotiate a plan, close follow-up; if abuse continues, refer for treatment 1

Substance Dependence

• Three or more criteria within 12 months including tolerance, withdrawal, loss of control, persistent desire to quit, time spent obtaining/using/recovering, reduced activities, continued use despite problems 1
• Intervention: Brief counseling, referral for specialty treatment, consider pharmacotherapy (naltrexone, buprenorphine, methadone), ongoing assessment and support 1

Special Considerations for High-Risk Substances

Recognize that not all substance use carries equal risk: 1

• Intrinsically high-risk substances: Heroin, methamphetamine, crack cocaine are associated with high risk of harm to self and others 1
• Lower (but not negligible) risk: Ecstasy and marijuana, though risk increases with young age, genetic predisposition, unstable social circumstances, heavy use, or impaired coping mechanisms 1

Role of Urine Drug Testing

Routine urine drug testing is NOT recommended for screening purposes. 1

Use urine drug testing selectively to:

• Support a suspected diagnosis 1
• Assess for polysubstance use 1
• Monitor treatment response 1

Implementation in Clinical Practice

Universal screening is justified despite insufficient evidence that screening alone improves outcomes, based on high prevalence (22.5 million persons with substance abuse/dependence), substantial morbidity and mortality, and proven effectiveness of early identification. 1

Practical Workflow

• Incorporate standardized screening into routine care of all adult patients 4
• Screen annually in established patients 1
• Use non-stigmatizing, person-first language, which positively affects care outcomes 4
• Administer screening via research staff, self-administration by patients, or healthcare providers 5

Common Pitfalls to Avoid

Do not use informal screening procedures or non-validated questionnaires - studies show only 1 in 3 physicians use validated tools despite 86% reporting they screen for substance use. 6

Recognize "drug-seeking" behaviors in context: Emergency calls near end of office hours, refusal of appropriate examination, repeated "loss" of prescriptions, tampering with prescriptions, reluctance to provide prior medical records, "doctor shopping" - these are common in substance use disorders but preoccupation with pain relief can be appropriate in patients with inadequate pain control. 7

Screen for comorbidities: Mental illness and intimate partner violence are common in patients with substance use disorders and must be assessed. 1