Is it important to screen patients, especially those with a history of substance use or being prescribed controlled substances, for their risk of addiction?

Screening for Addiction Risk in Patients

Yes, screening patients for addiction risk is important and justified based on the high prevalence and substantial morbidity and mortality of substance use disorders, despite insufficient evidence that screening alone improves outcomes. 1, 2

Universal Screening Approach

All patients should be screened annually using a validated single-question tool, regardless of whether they are prescribed controlled substances. 2 The American Academy of Family Physicians recommends asking: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" 1, 2 This single question demonstrates 90-100% sensitivity and 74% specificity for substance use disorders. 1, 2

When the Single-Question Screen is Positive

If a patient answers "1 or more times," administer the Drug Abuse Screening Test-10 (DAST-10) to quantify risk level. 1, 2 The DAST-10 has 90-100% sensitivity and 77% specificity and stratifies patients into:

• 0 points = Low risk: Reinforce healthy behavior 1
• 1-3 points = Moderate risk: Monitor and reassess 1, 2
• >3 points = Substance abuse or dependence: Requires intervention 1, 2

Risk Stratification for Controlled Substance Prescribing

For patients being prescribed controlled substances, particularly opioids, additional risk assessment is critical. 1 Patients with a history of substance use disorder should be carefully evaluated and risk-stratified in the same manner as all other patients—a history of addiction is not an absolute contraindication to receiving controlled substances. 1

High-Risk Indicators

The following factors identify patients at substantially elevated risk and warrant closer monitoring:

• History of opioid use disorder (likelihood ratio 17-22) 3
• History of other substance use disorder (likelihood ratio 4.2-17) 3
• Personality disorder (likelihood ratio 27) 3
• Concomitant prescription of atypical antipsychotics (likelihood ratio 17) 3
• Concurrent benzodiazepine and opioid prescriptions 4

Universal Precautions Approach

Apply a risk-benefit framework that views controlled substances as medications with unique risks to every patient—this "universal precautions approach" should be applied uniformly to help make fair and informed clinical decisions. 1 This approach neutralizes bias and reduces stigma in care. 1

Monitoring Patients on Controlled Substances

Urine Drug Testing Strategy

Routine urine drug testing is not recommended for screening purposes. 1, 2 However, urine drug testing can be used selectively to:

• Support a suspected diagnosis 1, 2
• Assess for polysubstance use 1, 2
• Monitor treatment response 1, 2

For patients on chronic controlled substance therapy, obtain baseline urine drug testing before initiating therapy and at least annually for stable patients without risk factors. 4 Higher-risk patients warrant quarterly or more frequent testing. 4

Critical Testing Pitfalls

Never dismiss patients from care based solely on urine drug test results—this constitutes patient abandonment. 4 Results should be used in combination with other clinical data for periodic evaluation of the treatment plan. 1

Always order confirmatory testing with gas chromatography-mass spectrometry (GC-MS) when results are unexpected or will impact clinical decisions, as standard immunoassay screens produce false positives from pseudoephedrine, trazodone, and other medications. 4

Comorbidity Screening

Screen all patients with substance use disorders for mental health disorders and intimate partner violence. 1 Rates of intimate partner violence exceed 50% in patients with drug use disorders in some settings. 1 Mental health disorders can be primary (predating substance use) or substance-induced, and primary disorders require standard psychological and pharmacologic therapies. 1

Intervention Based on Risk Level

After screening and risk stratification, tailor your intervention:

• Hazardous use: Brief counseling using motivational interviewing and ongoing assessment 1, 2
• Substance abuse: Brief counseling, negotiate a plan, and close follow-up 1, 2
• Substance dependence: Brief counseling, referral for specialty treatment, consider pharmacotherapy, and provide ongoing support 1, 2

Heroin, methamphetamine, and crack cocaine carry intrinsically high risk of harm to self and others, while ecstasy and marijuana have lower (but not negligible) risk. 1, 2 Physician judgment remains important in determining appropriate interventions for hazardous use. 1