Screening
The purpose of screening is to identify whether an individual has a substance use disorder that needs intervention.
Screening population
The US Preventive Services Task Force recommends screening for unhealthy drug use in all adults aged 18 years or older using tools such as the National Institute on Drug Abuse (NIDA) quick screen.[47]
High-risk populations should also undergo regular drug screening. These include:
Substance abusers with history of opioid use disorder or co-existing use of another drug such as alcohol[48]
Patients on chronic pain management medications; early identification may prevent abuse of opioid medications[37][49][50]
Patients referred from the criminal justice system
Psychiatric patients.
Additionally, the American College of Surgeons recommend that trauma centres carry out bedside screening for substance use problems in all physical trauma patients considered to be at higher risk of substance use disorders due to the presence of risk factors, e.g., positive urine drug screen results, suggestive history or examination findings, or positive answers to pre-screening questions such as social history questions enquiring about drug use.[51]
Universal screening for substance abuse is recommended in all pregnant women at the first antenatal visit by the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the American Society of Addiction Medicine.[52][53] Screening for pregnant women should take the form of a validated screening tool: for example, a questionnaire such as the NIDA quick screen, 4Ps screening method, or the CRAFFT Screening Interview (for women aged 26 years or younger).[52][53]
Screening locations
Pain clinics: location for patients consuming/demanding disproportionate amount of medications, thereby identifying patients at risk.[50]
Primary care physicians: the first contact point for a wide variety of patients, hence screening at this level can be beneficial.[22]
Emergency department: patients with a high degree of clinical suspicion should be screened for evidence of opioid use disorder and directed for appropriate interventions.
Trauma services or transplant services.
Universal screening: a novel concept initiated at some hospitals, which screens every patient admitted to the hospital, and offers intervention to those screening positive.
Level I screening procedures
Require minimal time and effort on the part of clinician/support worker during initial patient contact. Used primarily in outpatient clinics or pain management clinics.
Asking a few questions: questions pertaining to past drug use will guide the provider in evaluating if the patient needs to be screened further with level II procedures. The reluctance of some patients to be completely forthright in such self-diagnosis has been noted, and this may be particularly true on first presentation to some hospital settings, where no trusting relationship has yet been established between the patient and the provider.
Brief screening instrument, such as CAGE-AID (a modification of the CAGE questionnaire), a 4-item questionnaire that incorporates both alcohol and drug use. CAGE-AID questionnaire Opens in new window
Level II screening procedures
Require more time and effort to incorporate into routine practice than level I alternatives and are generally used in hospital settings.
Detailed interviews
Include specific questions and forms for self-completion (e.g., direct or open-ended questions regarding recent drug use, diagnosis of chronic pain illness, exposure to pain medications, frequency and duration of use).[54]
Should also include indirect inference from questions pertaining to trouble with law, history of accidents under influence, comorbid substance use disorders, and history of substance use disorder in family.
Specific abbreviated psychiatric structured interviews (e.g., Mini International Neuropsychiatric Interview - MINI), which take about 15 to 20 minutes, may also be used.[55]
Screening instruments
Drug Abuse Screening Test (DAST): usually a 10-item questionnaire, either interviewer- or self-administered. DAST items refer to the past 12 months rather than the lifetime.[56]
Dartmouth Assessment of Lifestyle Instrument (DALI): 18-item, interview-assisted screening instrument for substance use disorders with severe mental illness.[57]
Rapid Opioid Dependence Screen (RODS): 8-item, interviewer-administered questionnaire based on Diagnostic and statistical manual of mental disorders, 4th edition (DSM-4) criteria for substance dependence.[58]
Laboratory tests
Depending on the index of suspicion from the above tests, laboratory tests can serve as an adjunct to the screening process in establishing a diagnosis, and direct a physician towards the appropriate intervention.
Urine drug test (UDS): a urine drug test involves collection of a patient's urine sample in a specially designed secure cup and testing for the presence of drugs.
It is the most common test used.
First, the urine sample is screened for drugs using an analyser that performs immunoassay. If positive, further testing is used to confirm the findings by specific testing such as gas chromatography-mass spectroscopy.
Most of the opioids, including heroin, are metabolised into morphine or codeine and are detectable in the urine for 48 to 72 hours. Methadone is detectable for 7 to 9 days. Buprenorphine metabolites can be detected for up to 7 days. 6-monoacetylmorphine is a specific metabolite of heroin that confirms use of heroin. However, it is detectable in the urine for 4 hours only.
Routine opioid drug screen does not detect pethidine, fentanyl, pentazocine, dextromethorphan, buprenorphine, methadone, or naltrexone.
Saliva drug screen/oral fluid-based drug screen: alternatives that are easier to supervise than urine collection. However, there is less experience with cut-offs, and some compounds can produce false-positive results in saliva tests.
Hair and sweat test: permits a longer detection window (e.g., up to 3 months of use with hair: 1 cm of hair = 1 month of use). However, concentration of drugs in hair and sweat are low, requiring sensitive assays. At the time of writing, hair and sweat testing have not gained wide clinical acceptance.
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